Healthcare Provider Details

I. General information

NPI: 1972968303
Provider Name (Legal Business Name): AMISADAI PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/30/2015
Last Update Date: 01/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

AVENIDA GARRIDO MORALES ESQUINA CALLE SAN RAFAEL #12
FAJARDO PR
00738
US

IV. Provider business mailing address

HC 1 BOX 13216
RIO GRANDE PR
00745-9621
US

V. Phone/Fax

Practice location:
  • Phone: 787-657-8577
  • Fax: 787-657-8584
Mailing address:
  • Phone: 787-657-8577
  • Fax: 787-657-8584

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number18-F-3409
License Number StatePR
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: DARYLIS PIRIS
Title or Position: PRESIDENT
Credential:
Phone: 787-329-7708