=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962566794
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CONSEJO RENAL DE PUERTO RICO
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/19/2006
-----------------------------------------------------
Last Update Date | 07/29/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | #117 ELEANOR ROOSEVELT STREET SUITE 100A
-----------------------------------------------------
City | SAN JUAN
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00918
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-765-1500
-----------------------------------------------------
Fax | 787-765-1515
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 10542
-----------------------------------------------------
City | SAN JUAN
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00922-0542
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-765-1500
-----------------------------------------------------
Fax | 787-765-1515
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ACCOUNTANT
-----------------------------------------------------
Name | MRS. HILDA I RODRIGUEZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 787-765-1500
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number | 07-F-0315
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 09F2556
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------