Healthcare Provider Details

I. General information

NPI: 1164688719
Provider Name (Legal Business Name): ALFREDO ALICEA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/04/2008
Last Update Date: 08/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

#54 CALLE PARQUE SUSUA BAJA
SABANA GRANDE PR
00637
US

IV. Provider business mailing address

#54 CALLE PARQUE SUSUA BAJA
SABANA GRANDE PR
00637
US

V. Phone/Fax

Practice location:
  • Phone: 787-265-3330
  • Fax: 787-831-6716
Mailing address:
  • Phone: 787-265-3330
  • Fax: 787-831-6716

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number6277
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: