Provider Demographics
NPI:1326193970
Name:LOPEZ, WANDA L (LCDA)
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:L
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:LCDA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 URB ALTAMIRA
Mailing Address - Street 2:
Mailing Address - City:LARES
Mailing Address - State:PR
Mailing Address - Zip Code:00669-2901
Mailing Address - Country:US
Mailing Address - Phone:787-487-8373
Mailing Address - Fax:
Practice Address - Street 1:EDIFICIO MONTIJO # 5
Practice Address - Street 2:
Practice Address - City:BARCELONETA
Practice Address - State:PR
Practice Address - Zip Code:00617
Practice Address - Country:US
Practice Address - Phone:787-846-4542
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR4982183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist