Provider Demographics
NPI:1396810156
Name:SUPER FARMACIA SAN JOSE DE AIBONITO INC
Entity type:Organization
Organization Name:SUPER FARMACIA SAN JOSE DE AIBONITO INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RAFAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:RIVERA
Authorized Official - Suffix:
Authorized Official - Credentials:PH
Authorized Official - Phone:787-735-3025
Mailing Address - Street 1:PO BOX 2021
Mailing Address - Street 2:
Mailing Address - City:AIBONITO
Mailing Address - State:PR
Mailing Address - Zip Code:00705-2021
Mailing Address - Country:US
Mailing Address - Phone:787-735-3025
Mailing Address - Fax:787-735-2725
Practice Address - Street 1:SAN JOSE ST ESQ M SERRALLES
Practice Address - Street 2:300
Practice Address - City:AIBONITO
Practice Address - State:PR
Practice Address - Zip Code:00705
Practice Address - Country:US
Practice Address - Phone:787-735-3025
Practice Address - Fax:787-735-2725
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-21
Last Update Date:2017-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
PR19-F-34833336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2085519OtherPK
1022950001Medicare NSC