Provider Demographics
NPI:1730234899
Name:VIZCARRONDO, MAYTE LUCIELE
Entity type:Individual
Prefix:
First Name:MAYTE
Middle Name:LUCIELE
Last Name:VIZCARRONDO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 COND ANDALUCIA APT 3103
Mailing Address - Street 2:
Mailing Address - City:CAROLINA
Mailing Address - State:PR
Mailing Address - Zip Code:00987-2326
Mailing Address - Country:US
Mailing Address - Phone:787-630-7989
Mailing Address - Fax:787-768-0855
Practice Address - Street 1:CALLE IGNACIO ARZUAGA #5-E
Practice Address - Street 2:
Practice Address - City:CAROLINA
Practice Address - State:PR
Practice Address - Zip Code:00985
Practice Address - Country:US
Practice Address - Phone:787-769-0058
Practice Address - Fax:787-768-0855
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR5103183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist