=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427449032
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DI VELEZ, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/18/2015
-----------------------------------------------------
Last Update Date | 02/18/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | AVE. CHARDON #9
-----------------------------------------------------
City | SAN JUAN
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00918
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-919-7166
-----------------------------------------------------
Fax | 787-919-7164
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 210 JOSE OLIVER NEW CENTER PLAZA 806
-----------------------------------------------------
City | SAN JUAN
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00918
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-919-7166
-----------------------------------------------------
Fax | 787-919-7164
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. RAIMUNDO VELEZ
-----------------------------------------------------
Credential | PHARMACIST
-----------------------------------------------------
Telephone | 787-587-8742
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 17-F-3258
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------