Provider Demographics
NPI:1215250238
Name:MMR SUPERMARKET INC
Entity type:Organization
Organization Name:MMR SUPERMARKET INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ATTORNEY
Authorized Official - Prefix:
Authorized Official - First Name:IGNACIO
Authorized Official - Middle Name:
Authorized Official - Last Name:VIDAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-751-9393
Mailing Address - Street 1:PO BOX 1657
Mailing Address - Street 2:FARMACIA DON MODE
Mailing Address - City:TRUJILLO ALTO
Mailing Address - State:PR
Mailing Address - Zip Code:00977-1657
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:CARR 183, KM 1
Practice Address - Street 2:SAN LORENZO SHOPPING CENTER
Practice Address - City:SAN LORENZO
Practice Address - State:PR
Practice Address - Zip Code:00754
Practice Address - Country:US
Practice Address - Phone:787-715-1770
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-04
Last Update Date:2015-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR16F2799333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2124098OtherPK