Provider Demographics
NPI:1114488749
Name:CARRAQUILLO ROSA, TATIANA IVELISSE (CPTH)
Entity Type:Individual
Prefix:
First Name:TATIANA
Middle Name:IVELISSE
Last Name:CARRAQUILLO ROSA
Suffix:
Gender:F
Credentials:CPTH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 CALLE JOSE TOUS SOTO
Mailing Address - Street 2:
Mailing Address - City:SAN LORENZO
Mailing Address - State:PR
Mailing Address - Zip Code:00754
Mailing Address - Country:US
Mailing Address - Phone:787-388-6209
Mailing Address - Fax:
Practice Address - Street 1:BO CEIBA NORTE
Practice Address - Street 2:CARR 31 KM 24.5
Practice Address - City:JUNCOS
Practice Address - State:PR
Practice Address - Zip Code:00777
Practice Address - Country:US
Practice Address - Phone:787-705-2239
Practice Address - Fax:888-580-6779
Is Sole Proprietor?:No
Enumeration Date:2019-03-27
Last Update Date:2019-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR12056183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR6564767OtherDRIVER'LICENCE