Provider Demographics
NPI:1609587872
Name:MERCADO, GENESIS YEIDELIZ
Entity Type:Individual
Prefix:
First Name:GENESIS
Middle Name:YEIDELIZ
Last Name:MERCADO
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 1:4406 AVE MILITAR
Mailing Address - Street 2:
Mailing Address - City:ISABELA
Mailing Address - State:PR
Mailing Address - Zip Code:00662-4158
Mailing Address - Country:US
Mailing Address - Phone:787-872-5943
Mailing Address - Fax:
Practice Address - Street 1:CARR 459 KM 3.1 BO CAMASEYES
Practice Address - Street 2:
Practice Address - City:AGUADILLA
Practice Address - State:PR
Practice Address - Zip Code:00605
Practice Address - Country:US
Practice Address - Phone:787-891-8822
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-08
Last Update Date:2022-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR014789183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR014789Medicaid