Provider Demographics
NPI:1639222086
Name:FARMACIA SAN ANTONIO DE AGUADA INC
Entity Type:Organization
Organization Name:FARMACIA SAN ANTONIO DE AGUADA INC
Other - Org Name:FARMACIA SAN ANTONIO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VICTOR
Authorized Official - Middle Name:
Authorized Official - Last Name:GARCIA
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:787-868-2805
Mailing Address - Street 1:PO BOX 1061
Mailing Address - Street 2:
Mailing Address - City:AGUADA
Mailing Address - State:PR
Mailing Address - Zip Code:00602-1061
Mailing Address - Country:US
Mailing Address - Phone:787-868-2805
Mailing Address - Fax:787-252-0311
Practice Address - Street 1:AVE NATIVO ALERS DESVIO SUR
Practice Address - Street 2:
Practice Address - City:AGUADA
Practice Address - State:PR
Practice Address - Zip Code:00602-0991
Practice Address - Country:US
Practice Address - Phone:787-868-2805
Practice Address - Fax:787-252-0311
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-19
Last Update Date:2017-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
PR17F23003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2086301OtherPK
PR1320440002Medicaid