Provider Demographics
NPI:1598811648
Name:RODRIGUEZ, CARMELO
Entity Type:Individual
Prefix:
First Name:CARMELO
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 1:4028 CALLE AMBAR
Mailing Address - Street 2:LAGO HORIZONTE
Mailing Address - City:COTO LAUREL
Mailing Address - State:PR
Mailing Address - Zip Code:00780-2425
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:FARMACIA SAN ANTONIO
Practice Address - Street 2:149 TIERRA SANTA
Practice Address - City:VILLALBA
Practice Address - State:PR
Practice Address - Zip Code:00766
Practice Address - Country:US
Practice Address - Phone:787-847-1096
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR6243183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist