Provider Demographics
NPI:1043412646
Name:MARIO DE JESUS CRUZ INC DBA FARMACIA LA MILAGROSA
Entity Type:Organization
Organization Name:MARIO DE JESUS CRUZ INC DBA FARMACIA LA MILAGROSA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:MARIO
Authorized Official - Middle Name:DE JESUS
Authorized Official - Last Name:CRUZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-891-1060
Mailing Address - Street 1:PO BOX 907
Mailing Address - Street 2:
Mailing Address - City:AGUADILLA
Mailing Address - State:PR
Mailing Address - Zip Code:00605-0907
Mailing Address - Country:US
Mailing Address - Phone:787-891-1060
Mailing Address - Fax:787-882-5075
Practice Address - Street 1:AVE SAN CARLOS #1
Practice Address - Street 2:
Practice Address - City:AGUADILLA
Practice Address - State:PR
Practice Address - Zip Code:00603
Practice Address - Country:US
Practice Address - Phone:787-891-1060
Practice Address - Fax:787-882-5075
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR1255980001Medicare ID - Type UnspecifiedPROVIDER ID