Provider Demographics
NPI:1447643424
Name:SANTIAGO, JUAN
Entity type:Individual
Prefix:
First Name:JUAN
Middle Name:
Last Name:SANTIAGO
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:HC 4 BOX 43308
Mailing Address - Street 2:
Mailing Address - City:LARES
Mailing Address - State:PR
Mailing Address - Zip Code:00669-9431
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:379 AVENIDA LOS PATRIOTAS
Practice Address - Street 2:
Practice Address - City:LARES
Practice Address - State:PUERTO RICO
Practice Address - Zip Code:00669
Practice Address - Country:UM
Practice Address - Phone:787-897-2290
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-14
Last Update Date:2015-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR007994183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR007994OtherSTATE LICENSE