Provider Demographics
NPI:1134133069
Name:GENESIS PHARMACY
Entity Type:Organization
Organization Name:GENESIS PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:LUIS
Authorized Official - Middle Name:
Authorized Official - Last Name:CARRASQUILLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-839-5015
Mailing Address - Street 1:PO BOX 986
Mailing Address - Street 2:
Mailing Address - City:PATILLAS
Mailing Address - State:PR
Mailing Address - Zip Code:00723-0986
Mailing Address - Country:US
Mailing Address - Phone:787-839-5015
Mailing Address - Fax:
Practice Address - Street 1:CARRETERA #3 KM 123.0
Practice Address - Street 2:
Practice Address - City:PATILLAS
Practice Address - State:PR
Practice Address - Zip Code:00723
Practice Address - Country:US
Practice Address - Phone:787-839-5015
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-28
Last Update Date:2008-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR07F2072302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization