Provider Demographics
NPI:1578772356
Name:MEDICAL PHARMACY AND LAB
Entity Type:Organization
Organization Name:MEDICAL PHARMACY AND LAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENTE
Authorized Official - Prefix:MR
Authorized Official - First Name:MIGUEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:ROBLEDO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-707-1983
Mailing Address - Street 1:771 AVE ANDALUCIA
Mailing Address - Street 2:
Mailing Address - City:PUERTO NUEVO
Mailing Address - State:PR
Mailing Address - Zip Code:00921-1803
Mailing Address - Country:US
Mailing Address - Phone:787-707-1983
Mailing Address - Fax:787-706-8823
Practice Address - Street 1:AVENIDA ANDGLUCIA 771 PUERTO NUEVO
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00921-1803
Practice Address - Country:US
Practice Address - Phone:787-707-1943
Practice Address - Fax:787-706-8823
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-21
Last Update Date:2022-07-21
Deactivation Date:2007-07-17
Deactivation Code:
Reactivation Date:2007-08-21
Provider Licenses
StateLicense IDTaxonomies
PR302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR0084764Medicare ID - Type UnspecifiedPATRONAL MEDICARE MPL