Provider Demographics
NPI:1447539069
Name:FAJARDO, GUILLERMO ANTONIO (RPH)
Entity type:Individual
Prefix:
First Name:GUILLERMO
Middle Name:ANTONIO
Last Name:FAJARDO
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5984 AVE ISLA VERDE
Mailing Address - Street 2:WALGREENS
Mailing Address - City:CAROLINA
Mailing Address - State:PR
Mailing Address - Zip Code:00979-5776
Mailing Address - Country:US
Mailing Address - Phone:787-982-0390
Mailing Address - Fax:787-982-0570
Practice Address - Street 1:5984 AVE ISLA VERDE
Practice Address - Street 2:WALGREENS
Practice Address - City:CAROLINA
Practice Address - State:PR
Practice Address - Zip Code:00979-5776
Practice Address - Country:US
Practice Address - Phone:787-982-0390
Practice Address - Fax:787-982-0570
Is Sole Proprietor?:No
Enumeration Date:2011-08-12
Last Update Date:2011-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR4036183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist