1073816427 NPI number — DLR CONDADO PHARMACY

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073816427 NPI number — DLR CONDADO PHARMACY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DLR CONDADO PHARMACY
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1073816427
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/22/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 195417
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN JUAN
Provider Business Mailing Address State Name:
PR
Provider Business Mailing Address Postal Code:
00919-5417
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
787-758-0168
Provider Business Mailing Address Fax Number:
787-753-5906

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
186 CALLE JUAN P DUARTE
Provider Second Line Business Practice Location Address:
HATO REY
Provider Business Practice Location Address City Name:
SAN JUAN
Provider Business Practice Location Address State Name:
PR
Provider Business Practice Location Address Postal Code:
00917-3602
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
787-758-0168
Provider Business Practice Location Address Fax Number:
787-753-5906
Provider Enumeration Date:
12/07/2010

Additional Information

Authorized Official

Authorized Official Last Name:
DE LEON
Authorized Official First Name:
MANUEL
Authorized Official Middle Name:
Authorized Official Title or Position:
TREASURER
Authorized Official Telephone Number:
787-758-0138

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 15F2783 , registered in the state of PR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2127984 . This is a "PK" identifier . This identifiers is of the category "OTHER".




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