Healthcare Provider Details

I. General information

NPI: 1073806873
Provider Name (Legal Business Name): WANDA IVELISSE COLON RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/26/2011
Last Update Date: 05/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PR 190 & CAMPO RICO
CAROLINA PR
00979
US

IV. Provider business mailing address

URB. PALACIOS REALES NUM 86 C-19
TOA ALTA PR
00953
US

V. Phone/Fax

Practice location:
  • Phone: 787-762-1290
  • Fax:
Mailing address:
  • Phone: 787-359-3971
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number4967
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: