Healthcare Provider Details

I. General information

NPI: 1376885251
Provider Name (Legal Business Name): PANCHO BLU LLC DBA FARMACIAS ALIADAS GURABO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/19/2013
Last Update Date: 03/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

RD 189 RALPH'S PLAZA SUITE 6
GURABO PR
00778
US

IV. Provider business mailing address

STREET 4 #150 URB EL PARQUE
SAN LORENZO PR
00754
US

V. Phone/Fax

Practice location:
  • Phone: 787-736-7100
  • Fax: 787-736-0300
Mailing address:
  • Phone: 787-736-7100
  • Fax: 787-736-0300

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number15F3115
License Number StatePR
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number15F3115
License Number StatePR

VIII. Authorized Official

Name: EDWARD SAEZ
Title or Position: PRESIDENT
Credential:
Phone: 787-736-7100