Provider Demographics
NPI:1073393849
Name:ACEVEDO, TAIRA
Entity Type:Individual
Prefix:
First Name:TAIRA
Middle Name:
Last Name:ACEVEDO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:583 ESTANCIAS DE MEMBRILLO
Mailing Address - Street 2:
Mailing Address - City:CAMUY
Mailing Address - State:PR
Mailing Address - Zip Code:00627
Mailing Address - Country:US
Mailing Address - Phone:787-634-8003
Mailing Address - Fax:
Practice Address - Street 1:400 AVE LUIS MUNOZ RIVERA
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00918-3310
Practice Address - Country:US
Practice Address - Phone:787-296-8460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-29
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR2600183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist