=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174828461
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUPER FARMACIA AMADEO INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/18/2011
-----------------------------------------------------
Last Update Date | 04/09/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | CARRETERA 670 KM 8.4 SECTOR ALGARROBO
-----------------------------------------------------
City | VEGA BAJA
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00693
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-855-3473
-----------------------------------------------------
Fax | 787-807-5533
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | SUPER FARMACIA AMADEO INC. 74 CARR. 670
-----------------------------------------------------
City | VEGA BAJA
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00693-5155
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-855-3473
-----------------------------------------------------
Fax | 787-807-5533
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | ORLANDO GONZALEZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 787-346-3146
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0004X
-----------------------------------------------------
Taxonomy Name | Compounding Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 12-F2914
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------