Basic Information
| Provider Information | |||||||||
| NPI: | 1568063550 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ORTEGA | ||||||||
| FirstName: | JESSENIA | ||||||||
| MiddleName: | LAZARA | ||||||||
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| Credential: | PHARM D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12834 NW 18TH CT | ||||||||
| Address2: | |||||||||
| City: | PEMBROKE PINES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330282509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3059685739 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3200 NW 79TH ST | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331474600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3059138706 | ||||||||
| FaxNumber: | 3059138707 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/05/2020 | ||||||||
| LastUpdateDate: | 11/05/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | PS48364 | FL | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.