Healthcare Provider Details

I. General information

NPI: 1932563277
Provider Name (Legal Business Name): MARY HURTADODEMENDOZA PHARM D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2016
Last Update Date: 04/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

59 COURTLAND AVE 2M
STAMFORD CT
06902
US

IV. Provider business mailing address

59 COURTLAND AVE APT 2M
STAMFORD CT
06902-3497
US

V. Phone/Fax

Practice location:
  • Phone: 203-219-9523
  • Fax:
Mailing address:
  • Phone: 203-219-9523
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number0010411
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: