Healthcare Provider Details

I. General information

NPI: 1043620123
Provider Name (Legal Business Name): OWN BUSSINESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/29/2014
Last Update Date: 04/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1933 CALLE GUAYABO LOS CAOBOS
PONCE PR
00716
US

IV. Provider business mailing address

1933 CALLE GUAYABO LOS CAOBOS
PONCE PR
00716
US

V. Phone/Fax

Practice location:
  • Phone: 787-365-8662
  • Fax:
Mailing address:
  • Phone: 787-365-8662
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336M0003X
TaxonomyManaged Care Organization Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: BRENDA LEE GONZALEZ
Title or Position: PHARMACY TECHNICIAN
Credential:
Phone: 787-365-8662