Provider Demographics
NPI:1174639850
Name:FERNANDEZ, MARISOL
Entity Type:Individual
Prefix:
First Name:MARISOL
Middle Name:
Last Name:FERNANDEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:Q40 CALLE 19
Mailing Address - Street 2:URB VISTA AZUL
Mailing Address - City:ARECIBO
Mailing Address - State:PR
Mailing Address - Zip Code:00612-2639
Mailing Address - Country:US
Mailing Address - Phone:787-820-4747
Mailing Address - Fax:787-898-1859
Practice Address - Street 1:CARR 492 KM 2.3
Practice Address - Street 2:BO CORCOVADA
Practice Address - City:HATILLO
Practice Address - State:PR
Practice Address - Zip Code:00659
Practice Address - Country:US
Practice Address - Phone:787-820-4747
Practice Address - Fax:787-898-1859
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR4516183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist