Provider Demographics
NPI:1871846253
Name:PORTO, AVERIAL MADONNA (PHARM D)
Entity type:Individual
Prefix:
First Name:AVERIAL
Middle Name:MADONNA
Last Name:PORTO
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 SKEMP AVE
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26505-6333
Mailing Address - Country:US
Mailing Address - Phone:304-376-2460
Mailing Address - Fax:
Practice Address - Street 1:124 SKEMP AVE
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26505-6333
Practice Address - Country:US
Practice Address - Phone:304-376-2460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-22
Last Update Date:2012-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV0007917183500000X
PA447251183500000X
OH03132419183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist