Provider Demographics
NPI:1699710673
Name:FARMACIA SAN RAFAEL, INC
Entity type:Organization
Organization Name:FARMACIA SAN RAFAEL, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DEPARTMENT ADMINISTRATION/OWNER
Authorized Official - Prefix:MISS
Authorized Official - First Name:LUZ
Authorized Official - Middle Name:V
Authorized Official - Last Name:DIAZ REYES
Authorized Official - Suffix:
Authorized Official - Credentials:CFOM, AUX PHARMACY
Authorized Official - Phone:1787-722-4803
Mailing Address - Street 1:851 CALLE LAFAYETTE
Mailing Address - Street 2:PDA 20
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00909-2627
Mailing Address - Country:US
Mailing Address - Phone:787-722-4803
Mailing Address - Fax:787-721-3399
Practice Address - Street 1:851 CALLE LAFAYETTE
Practice Address - Street 2:PDA 20
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00909-2627
Practice Address - Country:US
Practice Address - Phone:787-722-4803
Practice Address - Fax:787-721-3399
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-16
Last Update Date:2014-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VACFOM0538332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR15-F-2298OtherPHARMACY LICENSE
PRDF-02802-7OtherHEALTH DEPARTMENT LICENSE
PRDF-02802-7OtherHEALTH DEPARTMENT LICENSE
PR4243590001Medicare UPIN