Provider Demographics
NPI:1114046315
Name:MEDINA, NELSON J
Entity Type:Individual
Prefix:
First Name:NELSON
Middle Name:J
Last Name:MEDINA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:URB. LAS VEGAS
Mailing Address - Street 2:CALLE 1 # A-10
Mailing Address - City:FLORIDA
Mailing Address - State:PR
Mailing Address - Zip Code:00650
Mailing Address - Country:US
Mailing Address - Phone:787-376-0775
Mailing Address - Fax:787-822-1996
Practice Address - Street 1:13 CALLE ANTONIO ALCAZAR
Practice Address - Street 2:
Practice Address - City:FLORIDA
Practice Address - State:PR
Practice Address - Zip Code:00650-1913
Practice Address - Country:US
Practice Address - Phone:787-822-0704
Practice Address - Fax:787-822-1996
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR3841183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician