Provider Demographics
NPI:1275682031
Name:SUPER FARMACIA VANGA, INC.
Entity Type:Organization
Organization Name:SUPER FARMACIA VANGA, INC.
Other - Org Name:SUPER FARMACIA VANGA, INC.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PEDRO
Authorized Official - Middle Name:JULIO
Authorized Official - Last Name:VANGA
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:787-751-0565
Mailing Address - Street 1:10 AVE SIMON MADERA
Mailing Address - Street 2:PARCELAS FALU
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00924-2231
Mailing Address - Country:US
Mailing Address - Phone:787-751-0565
Mailing Address - Fax:787-763-1263
Practice Address - Street 1:10 AVE SIMON MADERA
Practice Address - Street 2:PARCELAS FALU
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00924-2231
Practice Address - Country:US
Practice Address - Phone:787-751-0565
Practice Address - Fax:787-763-1263
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-10
Last Update Date:2014-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR16-F-32013336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR1263720001Medicare NSC