Healthcare Provider Details

I. General information

NPI: 1174578124
Provider Name (Legal Business Name): FLYING DIAMOND PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2006
Last Update Date: 05/12/2025
Certification Date: 05/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6140 MAE ANNE AVE STE 1B
RENO NV
89523-4707
US

IV. Provider business mailing address

PO BOX 5326
RENO NV
89513-5326
US

V. Phone/Fax

Practice location:
  • Phone: 775-787-1144
  • Fax: 775-787-1143
Mailing address:
  • Phone: 775-787-1144
  • Fax: 775-787-1143

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License NumberPH02114
License Number StateNV

VIII. Authorized Official

Name: MRS. TAMARA W AVERA
Title or Position: OFFICE MANAGER
Credential:
Phone: 775-787-1144