Provider Demographics
NPI:1679506125
Name:SUPER FARMACIA LIZETTE, INC
Entity Type:Organization
Organization Name:SUPER FARMACIA LIZETTE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LIZETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:RIVERA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-828-0755
Mailing Address - Street 1:PO BOX 1528
Mailing Address - Street 2:
Mailing Address - City:JAYUYA
Mailing Address - State:PR
Mailing Address - Zip Code:00664-2528
Mailing Address - Country:US
Mailing Address - Phone:787-828-0755
Mailing Address - Fax:787-828-6908
Practice Address - Street 1:103GMO ESTEVES ST
Practice Address - Street 2:
Practice Address - City:JAYUYA
Practice Address - State:PR
Practice Address - Zip Code:00664
Practice Address - Country:US
Practice Address - Phone:787-828-0755
Practice Address - Fax:787-828-6908
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-08
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR4130500001332B00000X
PR07-F-1565333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR07-F-1565OtherHEALTH DEPARMENT
PRDF-02185-7OtherAMSSCA
PRBS4887064OtherDEA
PRDF-02185-7OtherAMSSCA