Provider Demographics
NPI:1578787578
Name:ORTIZ, WANDA I (RPH)
Entity Type:Individual
Prefix:MRS
First Name:WANDA
Middle Name:I
Last Name:ORTIZ
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RR 4 BOX 3482
Mailing Address - Street 2:EL PEDREGAL
Mailing Address - City:BAYAMON
Mailing Address - State:PR
Mailing Address - Zip Code:00956-9416
Mailing Address - Country:US
Mailing Address - Phone:787-798-7641
Mailing Address - Fax:
Practice Address - Street 1:1324 CALLE CANADA
Practice Address - Street 2:DE DIEGO AVE
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00920-3860
Practice Address - Country:US
Practice Address - Phone:787-783-6545
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR813188183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist