=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972515617
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | YANQUISLANDIA CORP.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/12/2006
-----------------------------------------------------
Last Update Date | 05/15/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 139 SW 57TH AVE
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33144-3411
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-260-0693
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 139 SW 57TH AVE
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33144-3411
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | REYNALDO C CUBA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 305-260-0693
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | PH22592
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------