Provider Demographics
NPI:1972968303
Name:AMISADAI PHARMACY LLC
Entity type:Organization
Organization Name:AMISADAI PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DARYLIS
Authorized Official - Middle Name:
Authorized Official - Last Name:PIRIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-329-7708
Mailing Address - Street 1:HC 1 BOX 13216
Mailing Address - Street 2:
Mailing Address - City:RIO GRANDE
Mailing Address - State:PR
Mailing Address - Zip Code:00745-9621
Mailing Address - Country:US
Mailing Address - Phone:787-657-8577
Mailing Address - Fax:787-657-8584
Practice Address - Street 1:AVENIDA GARRIDO MORALES
Practice Address - Street 2:ESQUINA CALLE SAN RAFAEL #12
Practice Address - City:FAJARDO
Practice Address - State:PR
Practice Address - Zip Code:00738
Practice Address - Country:US
Practice Address - Phone:787-657-8577
Practice Address - Fax:787-657-8584
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-30
Last Update Date:2017-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR18-F-3409333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2163633OtherPK