Provider Demographics
NPI:1568695005
Name:CORDERO RIOS, WANDA I
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:I
Last Name:CORDERO RIOS
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:PO BOX 659
Mailing Address - Street 2:
Mailing Address - City:UTUADO
Mailing Address - State:PR
Mailing Address - Zip Code:00641-0659
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:CARR 111 KM 1.8
Practice Address - Street 2:
Practice Address - City:UTUADO
Practice Address - State:PR
Practice Address - Zip Code:00641-0659
Practice Address - Country:US
Practice Address - Phone:787-894-2185
Practice Address - Fax:787-814-0058
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-01
Last Update Date:2009-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR002293183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR002293OtherPHARMACIST LICENSE