Provider Demographics
NPI:1306940754
Name:SUPER FARMACIA CORCOVADA
Entity type:Organization
Organization Name:SUPER FARMACIA CORCOVADA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERVISOR
Authorized Official - Prefix:MR
Authorized Official - First Name:EDGARDO
Authorized Official - Middle Name:JOSUE
Authorized Official - Last Name:BARRETO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-820-4747
Mailing Address - Street 1:PO BOX 140328
Mailing Address - Street 2:
Mailing Address - City:ARECIBO
Mailing Address - State:PR
Mailing Address - Zip Code:00614-0328
Mailing Address - Country:US
Mailing Address - Phone:787-820-4747
Mailing Address - Fax:787-898-1859
Practice Address - Street 1:492 ROAD KM 2.3 CORCOVADA
Practice Address - Street 2:
Practice Address - City:HATILLO
Practice Address - State:PR
Practice Address - Zip Code:00659
Practice Address - Country:US
Practice Address - Phone:787-820-4747
Practice Address - Fax:787-898-1859
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-07
Last Update Date:2008-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR07F18063336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4022606OtherNABP