MEDICARE: DAMARIS ILLAS TECH.

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	183700000X	Pharmacy Technician	2123	PR

General Provider Information

NPI Number	:	1780719864
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DAMARIS ILLAS TECH.

Provider Business Mailing Address
First Line	:	CALLE STA. ELENA 1697
Second Line	:	URB. ALTAMESA
City	:	RIO PIEDRAS
State	:	PR
Zip	:	00921
Country	:	US
Telephone Number	:	787-765-6768
Fax Number	:	787-765-5937

Provider Business Practice Location Address
First Line	:	455 AVE PONCE DE LEON
Second Line	:	ESQ. RUIZ BELVIS FLORAL PARK
City	:	SAN JUAN
State	:	PR
Zip	:	00917-3711
Country	:	US
Telephone Number	:	787-765-6768
Fax Number	:	787-765-5937

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/22/2007
Last Update Date	:	07/08/2007

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