Basic Information
| Provider Information | |||||||||
| NPI: | 1326188053 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | METRO MAYAGUEZ, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | FARMACIA PEREA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 170 | ||||||||
| Address2: | |||||||||
| City: | MAYAGUEZ | ||||||||
| State: | PR | ||||||||
| PostalCode: | 006810170 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7878340101 | ||||||||
| FaxNumber: | 7872652455 | ||||||||
| Practice Location | |||||||||
| Address1: | 5 CALLE DE DIEGO E | ||||||||
| Address2: | ESQUINA DR. BASORA | ||||||||
| City: | MAYAGUEZ | ||||||||
| State: | PR | ||||||||
| PostalCode: | 006804811 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7878323208 | ||||||||
| FaxNumber: | 7878323157 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MAESTRE | ||||||||
| AuthorizedOfficialFirstName: | JAIME | ||||||||
| AuthorizedOfficialMiddleName: | F. | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7878340101 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MHSA | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | 08-F-2466 | PR | Y | Suppliers | Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 4024686 | 01 | PR | NCPDP | OTHER |