Provider Demographics
NPI:1497171490
Name:VEGA-DE JESUS, HILDA L
Entity Type:Individual
Prefix:
First Name:HILDA
Middle Name:L
Last Name:VEGA-DE JESUS
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 1:59 CALLE PRINCIPAL
Mailing Address - Street 2:PO BOX 23 PALMER
Mailing Address - City:RIO GRANDE
Mailing Address - State:PR
Mailing Address - Zip Code:00721-0023
Mailing Address - Country:US
Mailing Address - Phone:787-863-3518
Mailing Address - Fax:787-860-1280
Practice Address - Street 1:EASTERN REGIONAL SHOPPING CENTER
Practice Address - Street 2:CARRETERA #3
Practice Address - City:FAJARDO
Practice Address - State:PR
Practice Address - Zip Code:00738
Practice Address - Country:US
Practice Address - Phone:787-863-3518
Practice Address - Fax:787-860-1280
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-14
Last Update Date:2014-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR2721183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR2721OtherSTATE LICENSE