=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376270652
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LISANDRA SANTOS DIAZ PHARMACY INTERN -P3
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/05/2022
-----------------------------------------------------
Last Update Date | 08/05/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | EL JIBARO AVE AND PR 172
-----------------------------------------------------
City | CIDRA
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00739
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-739-4386
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 38 BDA FERRER
-----------------------------------------------------
City | CIDRA
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00739-3375
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-478-9590
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 2891
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------