Provider Demographics
NPI:1104282813
Name:LIZARDI, MAITE (9041)
Entity type:Individual
Prefix:
First Name:MAITE
Middle Name:
Last Name:LIZARDI
Suffix:
Gender:F
Credentials:9041
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RR01 BOX 14085
Mailing Address - Street 2:
Mailing Address - City:TOA ALTA
Mailing Address - State:PR
Mailing Address - Zip Code:00953
Mailing Address - Country:US
Mailing Address - Phone:939-280-5666
Mailing Address - Fax:
Practice Address - Street 1:RR 1 BOX 14085
Practice Address - Street 2:
Practice Address - City:TOA ALTA
Practice Address - State:PR
Practice Address - Zip Code:00953-9771
Practice Address - Country:US
Practice Address - Phone:939-280-5666
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-11
Last Update Date:2016-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR9041183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician