Provider Demographics
NPI:1649401654
Name:MEDEXPRESS DIABETIC SUPPLY
Entity type:Organization
Organization Name:MEDEXPRESS DIABETIC SUPPLY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PROPIETARIO
Authorized Official - Prefix:MR
Authorized Official - First Name:RAFAEL
Authorized Official - Middle Name:ROSARIO
Authorized Official - Last Name:PEGUERO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-636-6496
Mailing Address - Street 1:324 CALLE PALACIOS
Mailing Address - Street 2:APT 4
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00915-2165
Mailing Address - Country:US
Mailing Address - Phone:787-636-6496
Mailing Address - Fax:
Practice Address - Street 1:324 CALLE PALACIOS
Practice Address - Street 2:APT 4
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00915-2165
Practice Address - Country:US
Practice Address - Phone:787-636-6496
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-07
Last Update Date:2009-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR332BC3200X, 332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment