MEDICARE: VIDA LOPEZ CALDERON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1835P0018X	Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist	PS67503	FL

General Provider Information

NPI Number	:	1417758590
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VIDA LOPEZ CALDERON

Provider Business Mailing Address
First Line	:	8870 FONTAINEBLEAU BLVD APT 203
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33172-4427
Country	:	US
Telephone Number	:	786-269-6050
Fax Number	:

Provider Business Practice Location Address
First Line	:	8870 FONTAINEBLEAU BLVD APT 203
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33172-4427
Country	:	US
Telephone Number	:	786-269-6050
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/24/2025
Last Update Date	:	03/24/2025

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