Provider Demographics
NPI:1952517609
Name:JIMENEZ, WANDA (RPH)
Entity type:Individual
Prefix:
First Name:WANDA
Middle Name:
Last Name:JIMENEZ
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HC-05 BOX 10126 BO. PADILLA
Mailing Address - Street 2:
Mailing Address - City:COROZAL
Mailing Address - State:PR
Mailing Address - Zip Code:00783-9800
Mailing Address - Country:US
Mailing Address - Phone:787-859-7959
Mailing Address - Fax:787-859-8128
Practice Address - Street 1:HC-05 BOX 10126 BO. PADILLA
Practice Address - Street 2:CARR. 159 KM 8.4
Practice Address - City:COROZAL
Practice Address - State:PR
Practice Address - Zip Code:00783-9800
Practice Address - Country:US
Practice Address - Phone:787-859-7959
Practice Address - Fax:787-859-8128
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR3826183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist