Healthcare Provider Details

I. General information

NPI: 1114046315
Provider Name (Legal Business Name): NELSON J MEDINA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13 CALLE ANTONIO ALCAZAR
FLORIDA PR
00650-1913
US

IV. Provider business mailing address

URB. LAS VEGAS CALLE 1 # A-10
FLORIDA PR
00650
US

V. Phone/Fax

Practice location:
  • Phone: 787-822-0704
  • Fax: 787-822-1996
Mailing address:
  • Phone: 787-376-0775
  • Fax: 787-822-1996

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number3841
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: