Provider Demographics
NPI:1376093401
Name:HIS PHARMACY LLC
Entity Type:Organization
Organization Name:HIS PHARMACY LLC
Other - Org Name:HIS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CORALYS
Authorized Official - Middle Name:
Authorized Official - Last Name:MORALES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:939-717-5670
Mailing Address - Street 1:PASEO LOS CORALES II
Mailing Address - Street 2:766 CALLE MAR DEL NORTE
Mailing Address - City:DORADO
Mailing Address - State:PR
Mailing Address - Zip Code:00646-0000
Mailing Address - Country:US
Mailing Address - Phone:939-717-5670
Mailing Address - Fax:
Practice Address - Street 1:EDIFICIO PUGNADO CARR. 137 KM 7.2
Practice Address - Street 2:LOCAL 2 BO. PUGNADO
Practice Address - City:VEGA BAJA
Practice Address - State:PR
Practice Address - Zip Code:00693-0000
Practice Address - Country:US
Practice Address - Phone:787-965-7999
Practice Address - Fax:787-965-7998
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-13
Last Update Date:2017-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336S0011X
PR18-F-34033336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2164661OtherPK