Healthcare Provider Details

I. General information

NPI: 1649401654
Provider Name (Legal Business Name): MEDEXPRESS DIABETIC SUPPLY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2009
Last Update Date: 08/07/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

324 CALLE PALACIOS APT 4
SAN JUAN PR
00915-2165
US

IV. Provider business mailing address

324 CALLE PALACIOS APT 4
SAN JUAN PR
00915-2165
US

V. Phone/Fax

Practice location:
  • Phone: 787-636-6496
  • Fax:
Mailing address:
  • Phone: 787-636-6496
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number StatePR
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number StatePR

VIII. Authorized Official

Name: MR. RAFAEL ROSARIO PEGUERO
Title or Position: PROPIETARIO
Credential:
Phone: 787-636-6496