Provider Demographics
NPI:1962129890
Name:ROSENTAL, DEBORA GRACIELA
Entity type:Individual
Prefix:
First Name:DEBORA
Middle Name:GRACIELA
Last Name:ROSENTAL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3701 N COUNTRY CLUB DR APT 507
Mailing Address - Street 2:
Mailing Address - City:AVENTURA
Mailing Address - State:FL
Mailing Address - Zip Code:33180-1734
Mailing Address - Country:US
Mailing Address - Phone:305-336-5496
Mailing Address - Fax:
Practice Address - Street 1:2391 W 68TH ST
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33016-6816
Practice Address - Country:US
Practice Address - Phone:305-820-2122
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-21
Last Update Date:2022-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS38905183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPS38905Medicaid