Provider Demographics
NPI:1356844658
Name:RODRIGUEZ BADILLO, JORGE LUIS
Entity Type:Individual
Prefix:
First Name:JORGE
Middle Name:LUIS
Last Name:RODRIGUEZ BADILLO
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 3 BOX 34977
Mailing Address - Street 2:
Mailing Address - City:AGUADILLA
Mailing Address - State:PR
Mailing Address - Zip Code:00603-9485
Mailing Address - Country:US
Mailing Address - Phone:787-204-7633
Mailing Address - Fax:
Practice Address - Street 1:1052 AVE GENERAL RAMEY
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:PR
Practice Address - Zip Code:00690-1204
Practice Address - Country:US
Practice Address - Phone:787-890-3340
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-13
Last Update Date:2018-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR12292183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician