Provider Demographics
NPI:1841364239
Name:AIZA Y PEREZ CABAN
Entity type:Organization
Organization Name:AIZA Y PEREZ CABAN
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AIZA
Authorized Official - Middle Name:
Authorized Official - Last Name:PEREZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-877-0110
Mailing Address - Street 1:PO BOX 57
Mailing Address - Street 2:
Mailing Address - City:MOCA
Mailing Address - State:PR
Mailing Address - Zip Code:00676-0057
Mailing Address - Country:US
Mailing Address - Phone:787-877-0110
Mailing Address - Fax:787-818-0110
Practice Address - Street 1:CARR 110 KM 13 PT 0
Practice Address - Street 2:BO PUEBLO
Practice Address - City:MOCA
Practice Address - State:PR
Practice Address - Zip Code:00676
Practice Address - Country:US
Practice Address - Phone:787-877-0110
Practice Address - Fax:787-818-0110
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-20
Last Update Date:2017-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
PR17F20763336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR17-F-2076Medicaid
2087130OtherPK