Healthcare Provider Details

I. General information

NPI: 1679506125
Provider Name (Legal Business Name): SUPER FARMACIA LIZETTE, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103GMO ESTEVES ST
JAYUYA PR
00664
US

IV. Provider business mailing address

PO BOX 1528
JAYUYA PR
00664-2528
US

V. Phone/Fax

Practice location:
  • Phone: 787-828-0755
  • Fax: 787-828-6908
Mailing address:
  • Phone: 787-828-0755
  • Fax: 787-828-6908

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number4130500001
License Number StatePR
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number07-F-1565
License Number StatePR

VIII. Authorized Official

Name: LIZETTE RIVERA
Title or Position: OWNER
Credential:
Phone: 787-828-0755