Provider Demographics
NPI:1114001963
Name:FAME LLC
Entity type:Organization
Organization Name:FAME LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:FELIX
Authorized Official - Middle Name:A
Authorized Official - Last Name:MALDONADO
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:787-608-0140
Mailing Address - Street 1:CARRETERA 686
Mailing Address - Street 2:#105, EDIFICIO SAN MARTN
Mailing Address - City:VEGA BAJA
Mailing Address - State:PR
Mailing Address - Zip Code:00693
Mailing Address - Country:US
Mailing Address - Phone:787-858-1231
Mailing Address - Fax:787-858-0983
Practice Address - Street 1:105 CARR 686
Practice Address - Street 2:KM 17.9
Practice Address - City:VEGA BAJA
Practice Address - State:PR
Practice Address - Zip Code:00693-4551
Practice Address - Country:US
Practice Address - Phone:787-858-1231
Practice Address - Fax:787-858-0983
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2024-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR07-F-05483336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR039711500Medicaid
PRDF-04022-0OtherSUSTANCIAS CONTROLADAS
PRF-1097666OtherPHARMACY LICENSE
PR07-F-0548OtherSTATE REGISTRY