Healthcare Provider Details

I. General information

NPI: 1275682031
Provider Name (Legal Business Name): SUPER FARMACIA VANGA, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/10/2007
Last Update Date: 10/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 AVE SIMON MADERA PARCELAS FALU
SAN JUAN PR
00924-2231
US

IV. Provider business mailing address

10 AVE SIMON MADERA PARCELAS FALU
SAN JUAN PR
00924-2231
US

V. Phone/Fax

Practice location:
  • Phone: 787-751-0565
  • Fax: 787-763-1263
Mailing address:
  • Phone: 787-751-0565
  • Fax: 787-763-1263

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number16-F-3201
License Number StatePR

VIII. Authorized Official

Name: PEDRO JULIO VANGA
Title or Position: PRESIDENT
Credential: RPH
Phone: 787-751-0565