MEDICARE: SUPER FARMACIA JUANA DIAZ

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	333600000X	Pharmacy

General Provider Information

NPI Number	:	1093712838
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUPER FARMACIA JUANA DIAZ

Provider Business Mailing Address
First Line	:	27 CALLE TOMAS CARRION MADURO
Second Line	:
City	:	JUANA DIAZ
State	:	PR
Zip	:	00795-1642
Country	:	US
Telephone Number	:	787-837-2139
Fax Number	:	787-837-5911

Provider Business Practice Location Address
First Line	:	27 CALLE TOMAS CARRION MADURO
Second Line	:
City	:	JUANA DIAZ
State	:	PR
Zip	:	00795-1642
Country	:	US
Telephone Number	:	787-837-2139
Fax Number	:	787-837-5911

Authorized Official
Title or Position	:	PRESIDENT
Name	:	JULIO LUGO
Credential	:	RPH.
Telephone Number	:	787-837-2139

Provider Enumeration Date	:	07/07/2005
Last Update Date	:	11/05/2009

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