Healthcare Provider Details

I. General information

NPI: 1861570277
Provider Name (Legal Business Name): SUPER FARMACIA LIBERTAD INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2006
Last Update Date: 12/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

# 206 MUNOZ RIVERA ST.
FAJARDO PR
00738
US

IV. Provider business mailing address

PO BOX 1169
FAJARDO PR
00738-1169
US

V. Phone/Fax

Practice location:
  • Phone: 787-863-0810
  • Fax: 787-860-6666
Mailing address:
  • Phone: 787-863-0810
  • Fax: 787-860-6666

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number07-F-0415
License Number StatePR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MR. MANUEL E. FIGUEROA
Title or Position: PRESIDENT
Credential:
Phone: 787-863-0810