Provider Demographics
NPI:1245352129
Name:CORREA, ILIA
Entity type:Individual
Prefix:
First Name:ILIA
Middle Name:
Last Name:CORREA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:ACADIA ST #N56A, PARK GARDENS
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00926
Mailing Address - Country:US
Mailing Address - Phone:787-755-3039
Mailing Address - Fax:787-777-2799
Practice Address - Street 1:ALMACEN DE FARMACIA, CENTRO MEDICO
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00922-2129
Practice Address - Country:US
Practice Address - Phone:787-777-3535
Practice Address - Fax:787-777-2799
Is Sole Proprietor?:No
Enumeration Date:2007-04-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1779183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist