Provider Demographics
NPI:1336373273
Name:FARMACIA CONDADO MODERNO
Entity Type:Organization
Organization Name:FARMACIA CONDADO MODERNO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MIGUEL
Authorized Official - Middle Name:ANGEL
Authorized Official - Last Name:HERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:939-717-4634
Mailing Address - Street 1:CIUDAD JARDIN VILLAS DE GOLF 9
Mailing Address - Street 2:
Mailing Address - City:GURABO
Mailing Address - State:PR
Mailing Address - Zip Code:00778
Mailing Address - Country:UM
Mailing Address - Phone:939-717-4634
Mailing Address - Fax:
Practice Address - Street 1:URB CONDADO MODERNO
Practice Address - Street 2:C 18 M21
Practice Address - City:CAGUAS
Practice Address - State:PR
Practice Address - Zip Code:00725
Practice Address - Country:US
Practice Address - Phone:787-961-6770
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-06
Last Update Date:2009-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR11-F-27213336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy