Provider Demographics
NPI:1356893150
Name:PERDOMO, MARTIN
Entity type:Individual
Prefix:
First Name:MARTIN
Middle Name:
Last Name:PERDOMO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PR2 KM 2.2 KENNEDY AVE
Mailing Address - Street 2:MARGINAL JOHN F KENNEDY
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00936-0000
Mailing Address - Country:US
Mailing Address - Phone:787-522-3601
Mailing Address - Fax:787-522-3609
Practice Address - Street 1:PR-2 KM 2.2 KENNEDY AVE
Practice Address - Street 2:MARGINAL JOHN F KENNEDY
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00936-0000
Practice Address - Country:US
Practice Address - Phone:787-522-3601
Practice Address - Fax:787-522-3609
Is Sole Proprietor?:No
Enumeration Date:2016-10-27
Last Update Date:2016-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR4262183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist