Provider Demographics
NPI:1285381186
Name:REVERON MAYOL, MARK
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:REVERON MAYOL
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:WR20 AVE RAFAEL CARRION
Mailing Address - Street 2:
Mailing Address - City:CAROLINA
Mailing Address - State:PR
Mailing Address - Zip Code:00983-4712
Mailing Address - Country:US
Mailing Address - Phone:787-955-1255
Mailing Address - Fax:
Practice Address - Street 1:142 CALLE CARAZO
Practice Address - Street 2:
Practice Address - City:GUAYNABO
Practice Address - State:PR
Practice Address - Zip Code:00969-6408
Practice Address - Country:US
Practice Address - Phone:787-720-2934
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-10
Last Update Date:2022-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR7005183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist