Provider Demographics
NPI:1306028980
Name:HERNANDEZ, IDALIS
Entity Type:Individual
Prefix:MRS
First Name:IDALIS
Middle Name:
Last Name:HERNANDEZ
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:PO BOX 1013
Mailing Address - Street 2:
Mailing Address - City:SABANA SECA
Mailing Address - State:PR
Mailing Address - Zip Code:00952-1013
Mailing Address - Country:US
Mailing Address - Phone:787-720-8112
Mailing Address - Fax:
Practice Address - Street 1:11 CORCHADO STREET
Practice Address - Street 2:
Practice Address - City:CAGUAS
Practice Address - State:PR
Practice Address - Zip Code:00725
Practice Address - Country:US
Practice Address - Phone:787-743-2785
Practice Address - Fax:787-743-2785
Is Sole Proprietor?:No
Enumeration Date:2007-12-05
Last Update Date:2007-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR4170183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician