Provider Demographics
NPI:1720145238
Name:FARMACIA PONTEZUELA 24 LLC
Entity type:Organization
Organization Name:FARMACIA PONTEZUELA 24 LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:
Authorized Official - Last Name:SANCHEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-769-5240
Mailing Address - Street 1:PO BOX 29619
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00929-0619
Mailing Address - Country:US
Mailing Address - Phone:787-769-5240
Mailing Address - Fax:
Practice Address - Street 1:C 9 AVE PONTEZUELA VISTAMAR
Practice Address - Street 2:COND GOLDEN TOWER
Practice Address - City:CAROLINA
Practice Address - State:PR
Practice Address - Zip Code:00983
Practice Address - Country:US
Practice Address - Phone:787-769-5240
Practice Address - Fax:787-757-0021
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-03
Last Update Date:2017-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
PR18-F-28893336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2166399OtherPK