Provider Demographics
NPI:1447595442
Name:ROLDAN, WIFREDO
Entity Type:Individual
Prefix:MR
First Name:WIFREDO
Middle Name:
Last Name:ROLDAN
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 1:4 CALLE SAN JOSE N
Mailing Address - Street 2:ESQ. EUGENIO SANCHEZ
Mailing Address - City:GURABO
Mailing Address - State:PR
Mailing Address - Zip Code:00778-2429
Mailing Address - Country:US
Mailing Address - Phone:787-737-3355
Mailing Address - Fax:
Practice Address - Street 1:4 CALLE SAN JOSE N
Practice Address - Street 2:ESQ. EUGENIO SANCHEZ
Practice Address - City:GURABO
Practice Address - State:PR
Practice Address - Zip Code:00778-2429
Practice Address - Country:US
Practice Address - Phone:787-737-3355
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-01
Last Update Date:2012-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR2672183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician