Provider Demographics
NPI:1578931531
Name:CARDONA, IDA E
Entity Type:Individual
Prefix:
First Name:IDA
Middle Name:E
Last Name:CARDONA
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:HC 1 BOX 10051
Mailing Address - Street 2:
Mailing Address - City:COAMO
Mailing Address - State:PR
Mailing Address - Zip Code:00769-9701
Mailing Address - Country:US
Mailing Address - Phone:787-825-2807
Mailing Address - Fax:
Practice Address - Street 1:HC 1 BOX 10051
Practice Address - Street 2:
Practice Address - City:COAMO
Practice Address - State:PR
Practice Address - Zip Code:00769-9701
Practice Address - Country:US
Practice Address - Phone:787-825-2807
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-08
Last Update Date:2015-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR3219183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist