Provider Demographics
NPI:1982720454
Name:MARTINEZ, IVELISSE
Entity type:Individual
Prefix:
First Name:IVELISSE
Middle Name:
Last Name:MARTINEZ
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:P.O. BOX 597
Mailing Address - Street 2:
Mailing Address - City:SABANA HOYOS
Mailing Address - State:PR
Mailing Address - Zip Code:00688
Mailing Address - Country:US
Mailing Address - Phone:787-817-8041
Mailing Address - Fax:
Practice Address - Street 1:CARRETERA #2 KM 62.7
Practice Address - Street 2:SECTOR CANDELARIA
Practice Address - City:SABANA HOYOS
Practice Address - State:PR
Practice Address - Zip Code:00688
Practice Address - Country:US
Practice Address - Phone:787-881-2440
Practice Address - Fax:787-880-3258
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR3256183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician