Healthcare Provider Details

I. General information

NPI: 1982720454
Provider Name (Legal Business Name): IVELISSE MARTINEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/22/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CARRETERA #2 KM 62.7 SECTOR CANDELARIA
SABANA HOYOS PR
00688
US

IV. Provider business mailing address

P.O. BOX 597
SABANA HOYOS PR
00688
US

V. Phone/Fax

Practice location:
  • Phone: 787-881-2440
  • Fax: 787-880-3258
Mailing address:
  • Phone: 787-817-8041
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number3256
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: