Provider Demographics
NPI:1861937617
Name:ACOSTA, ADA MIRIAM
Entity type:Individual
Prefix:
First Name:ADA
Middle Name:MIRIAM
Last Name:ACOSTA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 CALLE MUNOZ RIVERA
Mailing Address - Street 2:
Mailing Address - City:CABO ROJO
Mailing Address - State:PR
Mailing Address - Zip Code:00623-4041
Mailing Address - Country:US
Mailing Address - Phone:787-851-1250
Mailing Address - Fax:787-851-1250
Practice Address - Street 1:45 CALLE MUNOZ RIVERA
Practice Address - Street 2:
Practice Address - City:CABO ROJO
Practice Address - State:PR
Practice Address - Zip Code:00623-4041
Practice Address - Country:US
Practice Address - Phone:787-851-1250
Practice Address - Fax:787-851-1250
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-04
Last Update Date:2017-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR328000183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician