=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083951966
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MIAA INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/11/2013
-----------------------------------------------------
Last Update Date | 01/31/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | CARR 100 KM 5.8 BO. MIRADERO
-----------------------------------------------------
City | CABO ROJO
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00623
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 939-910-7910
-----------------------------------------------------
Fax | 939-910-7911
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | CALLE BRAU # 44
-----------------------------------------------------
City | CABO ROJO
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00623
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/RPH/I/C
-----------------------------------------------------
Name | IVELISSE CINTRON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 939-910-7910
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 14F3077
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------