Healthcare Provider Details

I. General information

NPI: 1609915859
Provider Name (Legal Business Name): MRS. WANDA I DIAZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/05/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CALLE 1 B 6 VILLAS DEL MADRIGAL
CAROLINA PR
00987
US

IV. Provider business mailing address

CALLE 1 B 6 VILLAS DEL MADRIGAL
CAROLINA PR
00987-0000
US

V. Phone/Fax

Practice location:
  • Phone: 787-769-8224
  • Fax:
Mailing address:
  • Phone: 787-769-8224
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number005010
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: