Provider Demographics
NPI:1316391261
Name:HOSPITAL MENONITA CAGUAS INC
Entity Type:Organization
Organization Name:HOSPITAL MENONITA CAGUAS INC
Other - Org Name:FARMACIA Y GIFT SHOP MENONITA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:FARMACEUTICO REGENTE
Authorized Official - Prefix:
Authorized Official - First Name:BENIGNO
Authorized Official - Middle Name:
Authorized Official - Last Name:DOMINGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:787-653-0550
Mailing Address - Street 1:P.O. BOX 660
Mailing Address - Street 2:
Mailing Address - City:CAGUAS
Mailing Address - State:PR
Mailing Address - Zip Code:00725
Mailing Address - Country:US
Mailing Address - Phone:787-653-0550
Mailing Address - Fax:787-653-0538
Practice Address - Street 1:CARR. 172 CAGUAS A CIDRA URB. TURABO GARDENS
Practice Address - Street 2:
Practice Address - City:CAGUAS
Practice Address - State:PR
Practice Address - Zip Code:00725
Practice Address - Country:US
Practice Address - Phone:787-653-0550
Practice Address - Fax:787-653-0538
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-18
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
PR17F33403336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2159581OtherPK
PR400104Medicaid