Provider Demographics
NPI:1275740490
Name:FARMACIA GANDULLA
Entity Type:Organization
Organization Name:FARMACIA GANDULLA
Other - Org Name:FARMACIA SERRANO MIRADERO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:LEDA
Authorized Official - Middle Name:
Authorized Official - Last Name:SANTIAGO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-265-2684
Mailing Address - Street 1:MIRADERO PLAZA 1190 CARR 108
Mailing Address - Street 2:SUITE 101
Mailing Address - City:MAYAGUEZ
Mailing Address - State:PR
Mailing Address - Zip Code:00682
Mailing Address - Country:US
Mailing Address - Phone:787-265-2684
Mailing Address - Fax:787-265-2684
Practice Address - Street 1:CARR 108 KM 2 6 INT MIRADERO
Practice Address - Street 2:
Practice Address - City:MAYAGUEZ
Practice Address - State:PR
Practice Address - Zip Code:00682
Practice Address - Country:US
Practice Address - Phone:787-265-2684
Practice Address - Fax:787-265-2684
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-17
Last Update Date:2011-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
PR11F14593336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4020462OtherNCPDP PROVIDER IDENTIFICATION NUMBER