Provider Demographics
NPI:1760580690
Name:MARIO CRUZ
Entity Type:Organization
Organization Name:MARIO CRUZ
Other - Org Name:FARMACIA SAN ANTONIO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARIO
Authorized Official - Middle Name:
Authorized Official - Last Name:CRUZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-891-1060
Mailing Address - Street 1:PO BOX 907
Mailing Address - Street 2:
Mailing Address - City:AGUADILLA
Mailing Address - State:PR
Mailing Address - Zip Code:00605-0907
Mailing Address - Country:US
Mailing Address - Phone:787-891-1060
Mailing Address - Fax:787-890-3535
Practice Address - Street 1:CARR 110 KM 6.2
Practice Address - Street 2:BO MONTANO POBLADO SAN ANTONIO
Practice Address - City:AGUADILLA
Practice Address - State:PR
Practice Address - Zip Code:00605
Practice Address - Country:US
Practice Address - Phone:787-890-3535
Practice Address - Fax:787-890-3535
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2016-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
PR18-F-30273336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
2087526OtherPK