Provider Demographics
NPI:1770117509
Name:BIENESTAR PHARMACY GROUP
Entity type:Organization
Organization Name:BIENESTAR PHARMACY GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:R
Authorized Official - Last Name:DE TERREFORTE-DIAZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD, MPH
Authorized Official - Phone:939-545-0522
Mailing Address - Street 1:EDIFICIO CENTRAL
Mailing Address - Street 2:CALLE BALDORIOTY 165 NORTE BUZON #2
Mailing Address - City:AIBONITO
Mailing Address - State:PR
Mailing Address - Zip Code:00705
Mailing Address - Country:US
Mailing Address - Phone:939-545-0524
Mailing Address - Fax:939-545-0700
Practice Address - Street 1:CARR 718 KM 1.1
Practice Address - Street 2:BO PASTO, SECT. LA PLAYITA
Practice Address - City:AIBONITO
Practice Address - State:PR
Practice Address - Zip Code:00705
Practice Address - Country:US
Practice Address - Phone:787-303-0799
Practice Address - Fax:787-333-6188
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-02
Last Update Date:2022-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR039073300Medicaid