Provider Demographics
NPI:1215198304
Name:NOVA INFUSION & COMPOUNDING PHARMACY
Entity Type:Organization
Organization Name:NOVA INFUSION & COMPOUNDING PHARMACY
Other - Org Name:CEPA FAJARDO
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MILTON
Authorized Official - Middle Name:EZEQUIEL
Authorized Official - Last Name:SEGARRA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-720-1000
Mailing Address - Street 1:PO BOX 3968
Mailing Address - Street 2:
Mailing Address - City:GUAYNABO
Mailing Address - State:PR
Mailing Address - Zip Code:00970-3968
Mailing Address - Country:US
Mailing Address - Phone:787-720-1000
Mailing Address - Fax:787-653-3535
Practice Address - Street 1:404 AVE GENERAL VALERO
Practice Address - Street 2:
Practice Address - City:FAJARDO
Practice Address - State:PR
Practice Address - Zip Code:00738-3901
Practice Address - Country:US
Practice Address - Phone:787-720-1000
Practice Address - Fax:787-653-3535
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NOVA INFUSION & COPOUNDING PHARMACY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-06-20
Last Update Date:2008-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR4224780001Medicare NSC