Provider Demographics
NPI:1962569392
Name:MEDINA, SAMUEL
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:MEDINA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:C18 CALLE 5
Mailing Address - Street 2:ESTANCIAS DE SAN FERNANDO
Mailing Address - City:CAROLINA
Mailing Address - State:PR
Mailing Address - Zip Code:00985-5215
Mailing Address - Country:US
Mailing Address - Phone:787-438-4798
Mailing Address - Fax:787-768-4977
Practice Address - Street 1:C18 CALLE 5
Practice Address - Street 2:ESTANCIAS DE SAN FERNANDO
Practice Address - City:CAROLINA
Practice Address - State:PR
Practice Address - Zip Code:00985-5215
Practice Address - Country:US
Practice Address - Phone:787-438-4798
Practice Address - Fax:787-768-4977
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR2199183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR0720683OtherDRIVERS LICENCE