Provider Demographics
NPI:1336279322
Name:PEREZ, IDELISSE M
Entity Type:Individual
Prefix:MRS
First Name:IDELISSE
Middle Name:M
Last Name:PEREZ
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:#A 42 SANTA ANASTACIA URBANIZACION EL VIGIA
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00926
Mailing Address - Country:US
Mailing Address - Phone:787-783-9855
Mailing Address - Fax:787-782-7995
Practice Address - Street 1:1304 AVE JESUS T PINERO
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00921-1508
Practice Address - Country:US
Practice Address - Phone:787-783-9855
Practice Address - Fax:787-782-7995
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR004908183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist