Healthcare Provider Details

I. General information

NPI: 1144431578
Provider Name (Legal Business Name): LISMERY GORDILLO 3976585
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/25/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CARR 132 KM 22.1
PONCE PR
00728
US

IV. Provider business mailing address

#100 CONDOMINIO LA CEIBA APARTAMENTO 910
PONCE PR
00717
US

V. Phone/Fax

Practice location:
  • Phone: 787-290-1953
  • Fax:
Mailing address:
  • Phone: 787-449-4232
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number5971
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: