Healthcare Provider Details

I. General information

NPI: 1801436084
Provider Name (Legal Business Name): IVELLISSE ALDARONDO PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/15/2020
Last Update Date: 01/15/2020
Certification Date: 01/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2916 AVE MILITAR
ISABELA PR
00662-4060
US

IV. Provider business mailing address

2916 AVE MILITAR
ISABELA PR
00662-4060
US

V. Phone/Fax

Practice location:
  • Phone: 787-830-3189
  • Fax: 787-830-1573
Mailing address:
  • Phone: 787-830-3189
  • Fax: 787-830-1573

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number5313
License Number StatePR

VII. Legacy identifiers

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

# 1
Identifier126128
Identifier TypeOTHER
Identifier StatePR
Identifier IssuerCERTIFICATE OF REGISTRATION

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: