Healthcare Provider Details

I. General information

NPI: 1073816427
Provider Name (Legal Business Name): DLR CONDADO PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/07/2010
Last Update Date: 05/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

186 CALLE JUAN P DUARTE HATO REY
SAN JUAN PR
00917-3602
US

IV. Provider business mailing address

PO BOX 195417
SAN JUAN PR
00919-5417
US

V. Phone/Fax

Practice location:
  • Phone: 787-758-0168
  • Fax: 787-753-5906
Mailing address:
  • Phone: 787-758-0168
  • Fax: 787-753-5906

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number15F2783
License Number StatePR

VIII. Authorized Official

Name: MANUEL DE LEON
Title or Position: TREASURER
Credential:
Phone: 787-758-0138