MEDICARE: MS. MIRIAM GONGORA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183700000X	Pharmacy Technician	RPT29627	FL

General Provider Information

NPI Number	:	1417235722
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MIRIAM GONGORA

Provider Business Mailing Address
First Line	:	1990 W 56TH ST APT 1203
Second Line	:
City	:	HIALEAH
State	:	FL
Zip	:	33012-6918
Country	:	US
Telephone Number	:	786-380-6108
Fax Number	:

Provider Business Practice Location Address
First Line	:	1990 W 56 ST
Second Line	:	APT 1203
City	:	HIALEAH
State	:	FL
Zip	:	33012
Country	:	US
Telephone Number	:	786-380-6108
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/03/2011
Last Update Date	:	08/03/2011

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