Healthcare Provider Details

I. General information

NPI: 1386570158
Provider Name (Legal Business Name): LIDIA LARA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2026
Last Update Date: 06/20/2026
Certification Date: 06/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17804 W ENCINAS LN
GOODYEAR AZ
85338-6560
US

IV. Provider business mailing address

17804 W ENCINAS LN
GOODYEAR AZ
85338-6560
US

V. Phone/Fax

Practice location:
  • Phone: 602-413-7378
  • Fax:
Mailing address:
  • Phone: 602-413-7378
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License NumberT083395
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: