Healthcare Provider Details

I. General information

NPI: 1699073833
Provider Name (Legal Business Name): MRS. BRIGIDA MIMOSA JURADO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/12/2011
Last Update Date: 03/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6798 SHALLOWFORD RD
LEWISVILLE NC
27023-9724
US

IV. Provider business mailing address

4535 PEBBLE LAKE DR
PFAFFTOWN NC
27040-9241
US

V. Phone/Fax

Practice location:
  • Phone: 336-945-2106
  • Fax:
Mailing address:
  • Phone: 336-414-2640
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number18550
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: