=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104234467
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FARMACIA SAN PABLO SAN PEDRO INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/30/2014
-----------------------------------------------------
Last Update Date | 07/30/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 152 UNION AVE.
-----------------------------------------------------
City | LAJAS
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00667
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-475-5121
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 109
-----------------------------------------------------
City | LAJAS
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00667-0109
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-475-5121
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. ERASMO ASENCIO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 787-475-5121
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------