Basic Information
| Provider Information | |||||||||
| NPI: | 1245274554 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FARMACIA CENTRO MEDICO WILMA | ||||||||
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| Mailing Information | |||||||||
| Address1: | CARR 2 KM 39 5 ALGARRPBP | ||||||||
| Address2: | CALL BX 7001 | ||||||||
| City: | VEGA BAJA | ||||||||
| State: | PR | ||||||||
| PostalCode: | 00694 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | CARR 2 KM 39 5 ALGARRPBP | ||||||||
| Address2: | CALL BX 7001 | ||||||||
| City: | VEGA BAJA | ||||||||
| State: | PR | ||||||||
| PostalCode: | 00694 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7878581580 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | ROSA | ||||||||
| AuthorizedOfficialFirstName: | LUIS | ||||||||
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| AuthorizedOfficialTitleorPosition: | COMPTROLLER | ||||||||
| AuthorizedOfficialTelephone: | 7878581580 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | 07F0263 | PR | X | Suppliers | Pharmacy | 3336C0003X | X | Suppliers | Pharmacy | Community/Retail Pharmacy | 3336I0012X | X | Suppliers | Pharmacy | Institutional Pharmacy | 3336L0003X | X | Suppliers | Pharmacy | Long Term Care Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 4020436 | 01 | OTHER ID NUMBER-COMMERCIAL NUMBER | OTHER | 4000115 | 05 | PR | MEDICAID |