Provider Demographics
NPI:1437295094
Name:FARMACIA LAGO VISTA INC CALLE CAYMAN
Entity Type:Organization
Organization Name:FARMACIA LAGO VISTA INC CALLE CAYMAN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE-PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:VICMARIS
Authorized Official - Middle Name:
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-784-4585
Mailing Address - Street 1:PO BOX 51063
Mailing Address - Street 2:
Mailing Address - City:TOA BAJA
Mailing Address - State:PR
Mailing Address - Zip Code:00950-1063
Mailing Address - Country:US
Mailing Address - Phone:787-784-4585
Mailing Address - Fax:787-795-1465
Practice Address - Street 1:AVE BLVD 3386 LEVITTOWN
Practice Address - Street 2:PASEO CARMEN 3385-86
Practice Address - City:TOA BAJA
Practice Address - State:PR
Practice Address - Zip Code:00949
Practice Address - Country:US
Practice Address - Phone:787-784-4585
Practice Address - Fax:787-795-1465
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2018-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
PR19F02783336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2084147OtherPK