Provider Demographics
NPI:1477595015
Name:MIDWAY PHARMACY
Entity Type:Organization
Organization Name:MIDWAY PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMIN PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:LILLAIN
Authorized Official - Middle Name:
Authorized Official - Last Name:DOMINGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:787-873-1480
Mailing Address - Street 1:BO MAGINA 22S C/MARGINA/STE 2
Mailing Address - Street 2:
Mailing Address - City:SABANA GRANDE
Mailing Address - State:PR
Mailing Address - Zip Code:00637
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:BO RAYO CARR 117 INT 121 KM 4 2
Practice Address - Street 2:
Practice Address - City:SABANA GRANDE
Practice Address - State:PR
Practice Address - Zip Code:00637
Practice Address - Country:US
Practice Address - Phone:787-873-1480
Practice Address - Fax:787-804-1480
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR07F2067333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered333600000XSuppliersPharmacy
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4023937OtherOTHER ID NUMBER-COMMERCIAL NUMBER