Basic Information
| Provider Information | |||||||||
| NPI: | 1639631435 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FARMACIA DE LA COMUNIDAD HOSPITAL MENONITA DE GUAYAMA | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1650 | ||||||||
| Address2: | |||||||||
| City: | CIDRA | ||||||||
| State: | PR | ||||||||
| PostalCode: | 007391650 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7874341700 | ||||||||
| FaxNumber: | 7174341715 | ||||||||
| Practice Location | |||||||||
| Address1: | AVE PEDRO ALBIZU CAMPOS | ||||||||
| Address2: | URB LA HACIENDA | ||||||||
| City: | GUAYAMA | ||||||||
| State: | PR | ||||||||
| PostalCode: | 007850011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7874341700 | ||||||||
| FaxNumber: | 7874341715 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/02/2019 | ||||||||
| LastUpdateDate: | 04/02/2019 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | VAZQUEZ RIVERA | ||||||||
| AuthorizedOfficialFirstName: | LISSETTE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | BILLIN ANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7873746286 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | HOSPITAL MENONITA GUAYAMA INC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | Y | Suppliers | Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 4383339 | 05 | PR | MEDICAID |