Healthcare Provider Details

I. General information

NPI: 1154793693
Provider Name (Legal Business Name): JOHANNA I BURGOS RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/23/2015
Last Update Date: 10/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CARR 149 & 584 PLAZA JUANA DIAZ
JUANA DIAZ PR
00795-0000
US

IV. Provider business mailing address

6 CALLE 1 URB. TOMAS C MADURO
JUANA DIAZ PR
00795-0000
US

V. Phone/Fax

Practice location:
  • Phone: 787-260-0530
  • Fax: 847-396-2784
Mailing address:
  • Phone: 787-644-1466
  • Fax: 847-396-2784

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number004890
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: