Provider Demographics
NPI:1790812154
Name:FARMACIA CDT LARES MED CENTER
Entity Type:Organization
Organization Name:FARMACIA CDT LARES MED CENTER
Other - Org Name:FARMACIA CDT LARES MED CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:
Authorized Official - First Name:BALTSAR
Authorized Official - Middle Name:
Authorized Official - Last Name:CRUZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-897-1444
Mailing Address - Street 1:PO BOX 1427
Mailing Address - Street 2:
Mailing Address - City:LARES
Mailing Address - State:PR
Mailing Address - Zip Code:00669-1427
Mailing Address - Country:US
Mailing Address - Phone:787-897-1499
Mailing Address - Fax:787-897-1463
Practice Address - Street 1:CAR 111 AVE KM 2 9
Practice Address - Street 2:
Practice Address - City:LARES
Practice Address - State:PR
Practice Address - Zip Code:00669
Practice Address - Country:US
Practice Address - Phone:787-897-1499
Practice Address - Fax:787-897-1463
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-27
Last Update Date:2010-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR11F17383336C0002X
3336C0003X, 3336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4022062OtherNCPDP PROVIDER IDENTIFICATION NUMBER