Provider Demographics
NPI:1992123574
Name:PUEBLO INC
Entity type:Organization
Organization Name:PUEBLO INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP FINANCES
Authorized Official - Prefix:
Authorized Official - First Name:LUIS
Authorized Official - Middle Name:M
Authorized Official - Last Name:MALDONADO-PENA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-757-3131
Mailing Address - Street 1:PO BOX 1967
Mailing Address - Street 2:
Mailing Address - City:CAROLINA
Mailing Address - State:PR
Mailing Address - Zip Code:00984-1967
Mailing Address - Country:US
Mailing Address - Phone:787-757-3131
Mailing Address - Fax:787-793-8144
Practice Address - Street 1:1511 AVE PONCE DE LEON
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00909
Practice Address - Country:US
Practice Address - Phone:787-725-8112
Practice Address - Fax:787-725-8115
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PUEBLO INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-04-01
Last Update Date:2025-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR16F3186183500000X, 1835G0303X, 1835N1003X, 1835P1200X, 1835P1300X, 183700000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No183500000XPharmacy Service ProvidersPharmacistGroup - Multi-Specialty
No1835G0303XPharmacy Service ProvidersPharmacistGeriatricGroup - Multi-Specialty
No1835N1003XPharmacy Service ProvidersPharmacistNutrition SupportGroup - Multi-Specialty
No1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapyGroup - Multi-Specialty
No1835P1300XPharmacy Service ProvidersPharmacistPsychiatricGroup - Multi-Specialty
No183700000XPharmacy Service ProvidersPharmacy TechnicianGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR038204500Medicaid