Provider Demographics
NPI:1710414651
Name:DE LA CRUZ, ALTAGRACIA DEL CARMEN (TECNICO DE FARMACIA)
Entity Type:Individual
Prefix:
First Name:ALTAGRACIA
Middle Name:DEL CARMEN
Last Name:DE LA CRUZ
Suffix:
Gender:F
Credentials:TECNICO DE FARMACIA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:419 AVE PONCE DE LEON ESQ CALLE JUAN DUARTE
Mailing Address - Street 2:METROPOLIS APTS APT 710
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00917
Mailing Address - Country:US
Mailing Address - Phone:787-989-4416
Mailing Address - Fax:
Practice Address - Street 1:404 AVE BARBOSA ESQ CALLE SICILIA
Practice Address - Street 2:CDT DR KOPPISCH
Practice Address - City:RIO PIEDRAS
Practice Address - State:PR
Practice Address - Zip Code:00926
Practice Address - Country:US
Practice Address - Phone:787-294-0076
Practice Address - Fax:787-294-0076
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-22
Last Update Date:2017-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR011533183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183700000XPharmacy Service ProvidersPharmacy TechnicianGroup - Multi-Specialty