=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114046315
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NELSON J MEDINA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/28/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13 CALLE ANTONIO ALCAZAR
-----------------------------------------------------
City | FLORIDA
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00650-1913
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-822-0704
-----------------------------------------------------
Fax | 787-822-1996
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | URB. LAS VEGAS CALLE 1 # A-10
-----------------------------------------------------
City | FLORIDA
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00650
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-376-0775
-----------------------------------------------------
Fax | 787-822-1996
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183700000X
-----------------------------------------------------
Taxonomy Name | Pharmacy Technician
-----------------------------------------------------
License Number | 3841
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------