Provider Demographics
NPI:1174607451
Name:CRUZ, MARIO J
Entity type:Individual
Prefix:
First Name:MARIO
Middle Name:J
Last Name:CRUZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:AVE. SAN CARLOS ESQ CALLE MARINA
Mailing Address - Street 2:PO BOX 907
Mailing Address - City:AGUADILLA
Mailing Address - State:PR
Mailing Address - Zip Code:00605-0907
Mailing Address - Country:US
Mailing Address - Phone:787-891-1060
Mailing Address - Fax:787-882-5075
Practice Address - Street 1:AVE. SAN CARLOS ESQ CALLE MARINA
Practice Address - Street 2:
Practice Address - City:AGUADILLA
Practice Address - State:PR
Practice Address - Zip Code:00605-0907
Practice Address - Country:US
Practice Address - Phone:787-891-1060
Practice Address - Fax:787-882-5075
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR3326183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR3326OtherSTATE LICENSE