Provider Demographics
NPI:1326195405
Name:BLANCO, CARLOS
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:
Last Name:BLANCO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HC 1 BOX 6088
Mailing Address - Street 2:OROCOVIS
Mailing Address - City:OROCOVIS
Mailing Address - State:PR
Mailing Address - Zip Code:00720-9704
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:FARMACIA SAN ANTONIO
Practice Address - Street 2:149 TIERRA SANTA
Practice Address - City:VILLALBA
Practice Address - State:PR
Practice Address - Zip Code:00766
Practice Address - Country:US
Practice Address - Phone:787-847-1096
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR2939183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist