Provider Demographics
NPI:1720185655
Name:FARMACIA EL DIVINO NINO LLC
Entity Type:Organization
Organization Name:FARMACIA EL DIVINO NINO LLC
Other - Org Name:FARMACIA EL DIVINO NINO LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PHARMACIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:XOCHITL
Authorized Official - Middle Name:
Authorized Official - Last Name:RIVERA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-818-4839
Mailing Address - Street 1:835 CALLE CONCEPCION VERA
Mailing Address - Street 2:
Mailing Address - City:MOCA
Mailing Address - State:PR
Mailing Address - Zip Code:00676-5016
Mailing Address - Country:US
Mailing Address - Phone:787-818-4839
Mailing Address - Fax:787-877-8129
Practice Address - Street 1:CARR 110 KM 10.5
Practice Address - Street 2:835 CONCEPCION VERA
Practice Address - City:MOCA
Practice Address - State:PR
Practice Address - Zip Code:00676
Practice Address - Country:US
Practice Address - Phone:787-818-4839
Practice Address - Fax:787-877-8129
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2020-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
PR17-F-22893336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2087087OtherPK