=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750500302
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FARMACIA MEDIANIA INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/24/2007
-----------------------------------------------------
Last Update Date | 10/30/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | CARR 187 KM 7.0 MEDIANIA ALTA
-----------------------------------------------------
City | LOIZA
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00772
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-876-1927
-----------------------------------------------------
Fax | 787-256-2777
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 528 LOIZA
-----------------------------------------------------
City | LOIZA
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00772-0528
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-876-1927
-----------------------------------------------------
Fax | 787-256-2777
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. SANTIAGO MOLINA
-----------------------------------------------------
Credential | LCDO
-----------------------------------------------------
Telephone | 787-876-1927
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 13-F-0629
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------