=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215591102
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LAS AMERICAS FARMACIA LATINA INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/25/2019
-----------------------------------------------------
Last Update Date | 06/03/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1053-1 OLD COUNTRY RD
-----------------------------------------------------
City | RIVERHEAD
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11901-2128
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-591-2840
-----------------------------------------------------
Fax | 631-591-2841
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1053-1 OLD COUNTRY RD
-----------------------------------------------------
City | RIVERHEAD
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11901-2128
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-591-2840
-----------------------------------------------------
Fax | 631-591-2841
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | SEBASTIAN MESA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 631-591-2840
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------