Basic Information
| Provider Information | |||||||||
| NPI: | 1831845403 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MEDINA MATOS | ||||||||
| FirstName: | ROBERTO | ||||||||
| MiddleName: | CARLOS JESUS | ||||||||
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| Credential: | PHARMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | UNIVERSITY GARDENS AUSUBO ST. J-23 | ||||||||
| Address2: | |||||||||
| City: | ARECIBO | ||||||||
| State: | PR | ||||||||
| PostalCode: | 006127833 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7872370610 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | CAROLINA SHOPPING COURT, LOCAL 103-B | ||||||||
| Address2: | AVE 65TH DE INFANTERIA ESQ. ROBERTO CLEMENTE | ||||||||
| City: | CAROLINA | ||||||||
| State: | PR | ||||||||
| PostalCode: | 00987 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7877672626 | ||||||||
| FaxNumber: | 7877672626 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2022 | ||||||||
| LastUpdateDate: | 02/23/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 007012 | PR | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.