Healthcare Provider Details

I. General information

NPI: 1134133069
Provider Name (Legal Business Name): GENESIS PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2006
Last Update Date: 09/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CARRETERA #3 KM 123.0
PATILLAS PR
00723
US

IV. Provider business mailing address

PO BOX 986
PATILLAS PR
00723-0986
US

V. Phone/Fax

Practice location:
  • Phone: 787-839-5015
  • Fax:
Mailing address:
  • Phone: 787-839-5015
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number07F2072
License Number StatePR

VIII. Authorized Official

Name: MR. LUIS CARRASQUILLO
Title or Position: OWNER
Credential:
Phone: 787-839-5015