Provider Demographics
NPI:1073816427
Name:DLR CONDADO PHARMACY
Entity Type:Organization
Organization Name:DLR CONDADO PHARMACY
Other - Org Name:DLR CONDADO PHARMACY, INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:MANUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:DE LEON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-758-0138
Mailing Address - Street 1:PO BOX 195417
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00919-5417
Mailing Address - Country:US
Mailing Address - Phone:787-758-0168
Mailing Address - Fax:787-753-5906
Practice Address - Street 1:186 CALLE JUAN P DUARTE
Practice Address - Street 2:HATO REY
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00917-3602
Practice Address - Country:US
Practice Address - Phone:787-758-0168
Practice Address - Fax:787-753-5906
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-07
Last Update Date:2014-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
PR15F27833336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2127984OtherPK