Healthcare Provider Details

I. General information

NPI: 1992123574
Provider Name (Legal Business Name): PUEBLO INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/01/2014
Last Update Date: 08/19/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1511 AVE PONCE DE LEON
SAN JUAN PR
00909
US

IV. Provider business mailing address

PO BOX 1967
CAROLINA PR
00984-1967
US

V. Phone/Fax

Practice location:
  • Phone: 787-725-8112
  • Fax: 787-725-8115
Mailing address:
  • Phone: 787-757-3131
  • Fax: 787-793-8144

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number16F3186
License Number StatePR
# 2
Primary TaxonomyN
Taxonomy Code1835G0303X
TaxonomyGeriatric Pharmacist
License Number16F3186
License Number StatePR
# 3
Primary TaxonomyN
Taxonomy Code1835N1003X
TaxonomyNutrition Support Pharmacist
License Number16F3186
License Number StatePR
# 4
Primary TaxonomyN
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License Number16F3186
License Number StatePR
# 5
Primary TaxonomyN
Taxonomy Code1835P1300X
TaxonomyPsychiatric Pharmacist
License Number16F3186
License Number StatePR
# 6
Primary TaxonomyN
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number16F3186
License Number StatePR
# 7
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: LUIS M MALDONADO-PENA
Title or Position: VP FINANCES
Credential:
Phone: 787-757-3131