Healthcare Provider Details

I. General information

NPI: 1487634101
Provider Name (Legal Business Name): FARMACIA LA IDEAL, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/19/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 CALLE CELIS AGUILERA
SANTA ISABEL PR
00757-2622
US

IV. Provider business mailing address

4 CELIS AGUILERA ST. P.O. BOX 139
SANTA ISABEL PR
00757-0139
US

V. Phone/Fax

Practice location:
  • Phone: 787-845-4690
  • Fax: 787-845-4731
Mailing address:
  • Phone: 787-845-4690
  • Fax: 787-845-4731

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number07-F-0396
License Number StatePR

VIII. Authorized Official

Name: MRS. MARIA DEJESUS
Title or Position: PHARMACIST, CO-OWNER
Credential: BSPH
Phone: 787-845-4692