Provider Demographics
NPI:1073806873
Name:COLON, WANDA IVELISSE (RPH)
Entity Type:Individual
Prefix:MRS
First Name:WANDA
Middle Name:IVELISSE
Last Name:COLON
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:URB. PALACIOS REALES NUM 86 C-19
Mailing Address - Street 2:
Mailing Address - City:TOA ALTA
Mailing Address - State:PR
Mailing Address - Zip Code:00953
Mailing Address - Country:US
Mailing Address - Phone:787-359-3971
Mailing Address - Fax:
Practice Address - Street 1:PR 190 & CAMPO RICO
Practice Address - Street 2:
Practice Address - City:CAROLINA
Practice Address - State:PR
Practice Address - Zip Code:00979
Practice Address - Country:US
Practice Address - Phone:787-762-1290
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-26
Last Update Date:2011-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR4967183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist