Provider Demographics
NPI:1386621159
Name:ROMAN, MYRNA TERESA
Entity type:Individual
Prefix:
First Name:MYRNA
Middle Name:TERESA
Last Name:ROMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:ST. 119 KM 28.6
Mailing Address - Street 2:
Mailing Address - City:SAN SEBASTIAN
Mailing Address - State:PR
Mailing Address - Zip Code:00685
Mailing Address - Country:US
Mailing Address - Phone:787-896-4650
Mailing Address - Fax:787-896-4650
Practice Address - Street 1:ST. 119 KM. 28.6
Practice Address - Street 2:BOX 610
Practice Address - City:SAN SEBASTIAN
Practice Address - State:PR
Practice Address - Zip Code:00685
Practice Address - Country:US
Practice Address - Phone:787-896-4650
Practice Address - Fax:787-896-4650
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR2368183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR4959320001Medicare ID - Type Unspecified