Provider Demographics
NPI:1114144896
Name:ACEVEDO, JORGE LUIS (PHARMACIST)
Entity type:Individual
Prefix:
First Name:JORGE
Middle Name:LUIS
Last Name:ACEVEDO
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 543
Mailing Address - Street 2:
Mailing Address - City:LARES
Mailing Address - State:PR
Mailing Address - Zip Code:00669-0543
Mailing Address - Country:US
Mailing Address - Phone:787-897-4159
Mailing Address - Fax:787-897-3945
Practice Address - Street 1:CARRETERA 129
Practice Address - Street 2:KM 21.8 BO.CALLEJONES
Practice Address - City:LARES
Practice Address - State:PR
Practice Address - Zip Code:00669
Practice Address - Country:US
Practice Address - Phone:787-897-3945
Practice Address - Fax:787-897-3945
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR3363183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR3363OtherPHARMACIST LICENCE