Provider Demographics
NPI:1023234085
Name:MINERVA DE GRACIA CARRION
Entity type:Organization
Organization Name:MINERVA DE GRACIA CARRION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JEANNETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:TORRES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-883-4140
Mailing Address - Street 1:PO BOX 720
Mailing Address - Street 2:
Mailing Address - City:VEGA ALTA
Mailing Address - State:PR
Mailing Address - Zip Code:00692-0720
Mailing Address - Country:US
Mailing Address - Phone:787-883-4140
Mailing Address - Fax:787-270-3526
Practice Address - Street 1:#36 CALLE LUIS MUNOZ RIVERA
Practice Address - Street 2:
Practice Address - City:VEGA ALTA
Practice Address - State:PR
Practice Address - Zip Code:00692-0720
Practice Address - Country:US
Practice Address - Phone:787-883-4140
Practice Address - Fax:787-270-3526
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-18
Last Update Date:2008-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR09F0800333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy