Provider Demographics
NPI:1770602906
Name:MEDINA, TOMAS
Entity type:Individual
Prefix:
First Name:TOMAS
Middle Name:
Last Name:MEDINA
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:COLINAS FAIRVIEW STREET 223 # 4P34
Mailing Address - Street 2:
Mailing Address - City:TRUJILLLO ALTO
Mailing Address - State:PR
Mailing Address - Zip Code:00976
Mailing Address - Country:US
Mailing Address - Phone:787-777-0411
Mailing Address - Fax:787-777-0409
Practice Address - Street 1:SUPERMERCADO PUEBLO PLAZA LAS AMERICAS
Practice Address - Street 2:ONE STOP PRESCRIPTONS LAS AMERICAS
Practice Address - City:HATO REY
Practice Address - State:PR
Practice Address - Zip Code:00919
Practice Address - Country:US
Practice Address - Phone:787-777-0411
Practice Address - Fax:787-777-0409
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1778183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician