Provider Demographics
NPI:1083831747
Name:SUPER FARMACIA COROZAL
Entity Type:Organization
Organization Name:SUPER FARMACIA COROZAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:EFRAIN
Authorized Official - Middle Name:
Authorized Official - Last Name:HERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:LCDO
Authorized Official - Phone:787-859-2617
Mailing Address - Street 1:CARR.159 CENTRO COMERCIAL VILLAGE
Mailing Address - Street 2:
Mailing Address - City:COROZAL
Mailing Address - State:PR
Mailing Address - Zip Code:00783
Mailing Address - Country:US
Mailing Address - Phone:787-859-2617
Mailing Address - Fax:787-802-1098
Practice Address - Street 1:CARRETERA 159 CORAZAL SHOPPING VILLAGE
Practice Address - Street 2:
Practice Address - City:COROZAL
Practice Address - State:PR
Practice Address - Zip Code:00783
Practice Address - Country:US
Practice Address - Phone:787-859-2617
Practice Address - Fax:787-802-1098
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-20
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR2460183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty