Provider Demographics
NPI:1578682712
Name:RODRIGUEZ, MARIANO
Entity Type:Individual
Prefix:MR
First Name:MARIANO
Middle Name:
Last Name:RODRIGUEZ
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 1:69 JARDINES DEL PARQUE
Mailing Address - Street 2:BLVD. MEDIA LUNA PH 2904
Mailing Address - City:CAROLINA
Mailing Address - State:PR
Mailing Address - Zip Code:00987
Mailing Address - Country:US
Mailing Address - Phone:787-701-5605
Mailing Address - Fax:
Practice Address - Street 1:N-15 AVE PRINCIPAL
Practice Address - Street 2:TOA ALTA HEIGHTS
Practice Address - City:TOA ALTA
Practice Address - State:PR
Practice Address - Zip Code:00953
Practice Address - Country:US
Practice Address - Phone:787-797-7615
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR3551183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician