Provider Demographics
NPI:1962113969
Name:CAMPANA CISNEROS, MARIA DEL CARMEN (PHARMACIST)
Entity type:Individual
Prefix:
First Name:MARIA DEL CARMEN
Middle Name:
Last Name:CAMPANA CISNEROS
Suffix:
Gender:F
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16900 N BAY RD APT 1607
Mailing Address - Street 2:
Mailing Address - City:SUNNY ISLES BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33160-4270
Mailing Address - Country:US
Mailing Address - Phone:305-298-3260
Mailing Address - Fax:
Practice Address - Street 1:700 SE 3RD AVE
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33316-1139
Practice Address - Country:US
Practice Address - Phone:954-761-4534
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-09
Last Update Date:2022-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS37221183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1225530702OtherPHARMACY