Provider Demographics
NPI:1407231905
Name:CARBALLO, AGNERIS
Entity Type:Individual
Prefix:
First Name:AGNERIS
Middle Name:
Last Name:CARBALLO
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:HC 2 BOX 6314
Mailing Address - Street 2:BARRANCAS
Mailing Address - City:BARRANQUITAS
Mailing Address - State:PR
Mailing Address - Zip Code:00794-9213
Mailing Address - Country:US
Mailing Address - Phone:787-857-2750
Mailing Address - Fax:787-857-0707
Practice Address - Street 1:96 CALLE BARCELO
Practice Address - Street 2:
Practice Address - City:BARRANQUITAS
Practice Address - State:PR
Practice Address - Zip Code:00794-1614
Practice Address - Country:US
Practice Address - Phone:787-857-2750
Practice Address - Fax:787-857-0707
Is Sole Proprietor?:No
Enumeration Date:2015-07-25
Last Update Date:2015-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR6316183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician