Provider Demographics
NPI:1396347126
Name:MEDINA ROSA, MARIELIS (RPH)
Entity type:Individual
Prefix:
First Name:MARIELIS
Middle Name:
Last Name:MEDINA ROSA
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 175
Mailing Address - Street 2:
Mailing Address - City:QUEBRADILLAS
Mailing Address - State:PR
Mailing Address - Zip Code:00678-0175
Mailing Address - Country:US
Mailing Address - Phone:178-741-5026
Mailing Address - Fax:
Practice Address - Street 1:17705 CARRETERA #2 EDIFICIO #2
Practice Address - Street 2:
Practice Address - City:AGUADILLA
Practice Address - State:PR
Practice Address - Zip Code:00603
Practice Address - Country:US
Practice Address - Phone:787-819-3930
Practice Address - Fax:787-819-3938
Is Sole Proprietor?:No
Enumeration Date:2020-11-16
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR006780183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist