Provider Demographics
NPI:1629640388
Name:FUENTES PAYAN, WILMARIE
Entity Type:Individual
Prefix:
First Name:WILMARIE
Middle Name:
Last Name:FUENTES PAYAN
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:PO BOX 104
Mailing Address - Street 2:
Mailing Address - City:LA PLATA
Mailing Address - State:PR
Mailing Address - Zip Code:00786-0104
Mailing Address - Country:US
Mailing Address - Phone:787-518-3428
Mailing Address - Fax:
Practice Address - Street 1:CVS PHARMACY 2 STREET 178 CAPARRA TERRACE
Practice Address - Street 2:
Practice Address - City:GUAYNABO
Practice Address - State:PR
Practice Address - Zip Code:00966
Practice Address - Country:US
Practice Address - Phone:787-706-3600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-13
Last Update Date:2021-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR2070183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty