Provider Demographics
NPI:1588326615
Name:LOPEZ CORDERO, INDRA MARIE
Entity type:Individual
Prefix:
First Name:INDRA
Middle Name:MARIE
Last Name:LOPEZ CORDERO
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 1:2550 AVE DE DIEGO
Mailing Address - Street 2:
Mailing Address - City:CAROLINA
Mailing Address - State:PR
Mailing Address - Zip Code:00987-4800
Mailing Address - Country:US
Mailing Address - Phone:787-762-8412
Mailing Address - Fax:787-762-8479
Practice Address - Street 1:2550 AVE DE DIEGO
Practice Address - Street 2:
Practice Address - City:CAROLINA
Practice Address - State:PR
Practice Address - Zip Code:00987-4800
Practice Address - Country:US
Practice Address - Phone:787-762-8412
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-06
Last Update Date:2021-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR2862183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist