Basic Information
| Provider Information | |||||||||
| NPI: | 1497416945 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DEPARTAMENTO DE SALUD OFICIAL | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 191079 | ||||||||
| Address2: | |||||||||
| City: | SAN JUAN | ||||||||
| State: | PR | ||||||||
| PostalCode: | 009191079 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7877773232 | ||||||||
| FaxNumber: | 7877568907 | ||||||||
| Practice Location | |||||||||
| Address1: | PUERTO RICO MEDICAL CENTER | ||||||||
| Address2: | |||||||||
| City: | RIO PIEDRAS | ||||||||
| State: | PR | ||||||||
| PostalCode: | 009191079 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7877773232 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/06/2022 | ||||||||
| LastUpdateDate: | 01/06/2022 | ||||||||
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| AuthorizedOfficialLastName: | DIAZ | ||||||||
| AuthorizedOfficialFirstName: | VICTOR | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7877773232 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MHSA | ||||||||
| NPICertificationDate: | 01/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0003X | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | F-839165 | 01 | PR | GOBIERNO DE PUERTO RICO, DEPARTAMENTO DE SALUD | OTHER |