=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548343197
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FARMACIA LA INMACULADA INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/24/2006
-----------------------------------------------------
Last Update Date | 02/28/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5 CALLE ALMODOVAR
-----------------------------------------------------
City | JUNCOS
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00777-3302
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-734-4399
-----------------------------------------------------
Fax | 787-734-2565
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1753
-----------------------------------------------------
City | JUNCOS
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00777-1753
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-734-4399
-----------------------------------------------------
Fax | 787-734-2565
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | JOSE ROSA
-----------------------------------------------------
Credential | PHARMACIST
-----------------------------------------------------
Telephone | 787-734-4399
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 19F2926
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------