Healthcare Provider Details

I. General information

NPI: 1124303201
Provider Name (Legal Business Name): GREGORINA ALTAGRACIA CAMPUSANO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/20/2011
Last Update Date: 03/03/2026
Certification Date: 03/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

402 S JEFFERSON ST
FREDERICK MD
21701-6208
US

IV. Provider business mailing address

12818 CLOVERLEAF CENTER DR
GERMANTOWN MD
20874-7217
US

V. Phone/Fax

Practice location:
  • Phone: 301-663-4861
  • Fax:
Mailing address:
  • Phone: 202-714-4488
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number17085
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: