=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093792202
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FARMACIA SAN PABLO, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/29/2005
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 64 CALLE BARCELO
-----------------------------------------------------
City | CIDRA
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00739-3438
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-739-8300
-----------------------------------------------------
Fax | 787-739-6300
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 64 CALLE BARCELO
-----------------------------------------------------
City | CIDRA
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00739-3438
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-739-8300
-----------------------------------------------------
Fax | 787-739-6300
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MRS. LOURDES BERRIOS
-----------------------------------------------------
Credential | RPH.
-----------------------------------------------------
Telephone | 787-739-8300
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 07-F-0559
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------