Provider Demographics
NPI:1679760151
Name:FARMACIA SAN LAZARO
Entity Type:Organization
Organization Name:FARMACIA SAN LAZARO
Other - Org Name:FARMACIA SAN LAZARO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:RODRIGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-251-5930
Mailing Address - Street 1:AVE. SANTA JUANITA BR6-BR7
Mailing Address - Street 2:SANTA JUANITA
Mailing Address - City:BAYAMON
Mailing Address - State:PR
Mailing Address - Zip Code:00956-1616
Mailing Address - Country:US
Mailing Address - Phone:787-251-5930
Mailing Address - Fax:787-780-8671
Practice Address - Street 1:AVE. SANTA JUANITA BR6-BR7
Practice Address - Street 2:SANTA JUANITA
Practice Address - City:BAYAMON
Practice Address - State:PR
Practice Address - Zip Code:00956-1616
Practice Address - Country:US
Practice Address - Phone:787-251-5930
Practice Address - Fax:787-780-8671
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-28
Last Update Date:2019-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
PR19F25313336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR4025828Medicaid
2139202OtherPK