Provider Demographics
NPI:1770614166
Name:FARMACIA IDELISSE,INC.
Entity type:Organization
Organization Name:FARMACIA IDELISSE,INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANA LOIDA
Authorized Official - Middle Name:
Authorized Official - Last Name:RODRIGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:787-730-3508
Mailing Address - Street 1:PO BOX 4316
Mailing Address - Street 2:
Mailing Address - City:BAYAMON
Mailing Address - State:PR
Mailing Address - Zip Code:00958-1316
Mailing Address - Country:US
Mailing Address - Phone:787-730-3508
Mailing Address - Fax:787-730-7949
Practice Address - Street 1:CARR. 167 KM 9.5
Practice Address - Street 2:BARRIO DAJAOS
Practice Address - City:BAYAMON
Practice Address - State:PR
Practice Address - Zip Code:00956
Practice Address - Country:US
Practice Address - Phone:787-730-3508
Practice Address - Fax:787-730-7949
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2007-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR09-F-02253336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy