Provider Demographics
NPI:1568820454
Name:ALICEA, JUAN ALBERTO (PT)
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:ALBERTO
Last Name:ALICEA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HC 2 BOX 5171
Mailing Address - Street 2:
Mailing Address - City:VILLALBA
Mailing Address - State:PR
Mailing Address - Zip Code:00766-9862
Mailing Address - Country:US
Mailing Address - Phone:787-847-9393
Mailing Address - Fax:787-847-9292
Practice Address - Street 1:CARR 149 KM 57.4
Practice Address - Street 2:BO. TIERRA SANTA
Practice Address - City:VILLALBA
Practice Address - State:PR
Practice Address - Zip Code:00766-9862
Practice Address - Country:US
Practice Address - Phone:787-847-9393
Practice Address - Fax:787-847-9292
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-05
Last Update Date:2016-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR10808183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR10808OtherLICENCIA