Provider Demographics
NPI:1386853299
Name:RODRIGUEZ, ROBERTO (LIC)
Entity Type:Individual
Prefix:MR
First Name:ROBERTO
Middle Name:
Last Name:RODRIGUEZ
Suffix:
Gender:M
Credentials:LIC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:62 CALLE SOCORRO
Mailing Address - Street 2:
Mailing Address - City:QUEBRADILLAS
Mailing Address - State:PR
Mailing Address - Zip Code:00678-1854
Mailing Address - Country:US
Mailing Address - Phone:787-895-6912
Mailing Address - Fax:787-895-6912
Practice Address - Street 1:62 CALLE SOCORRO
Practice Address - Street 2:
Practice Address - City:QUEBRADILLAS
Practice Address - State:PR
Practice Address - Zip Code:00678-1854
Practice Address - Country:US
Practice Address - Phone:787-895-6912
Practice Address - Fax:787-895-6912
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR07-F-1577183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist