Healthcare Provider Details

I. General information

NPI: 1134655327
Provider Name (Legal Business Name): CORAL CRUZ PHARMACIST
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2017
Last Update Date: 05/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6501 LOISDALE CT
SPRINGFIELD VA
22150-1826
US

IV. Provider business mailing address

300 YOAKUM PKWY APT 903
ALEXANDRIA VA
22304-4057
US

V. Phone/Fax

Practice location:
  • Phone: 703-922-1014
  • Fax:
Mailing address:
  • Phone: 720-935-4172
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number0018850
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code1835P2201X
TaxonomyAmbulatory Care Pharmacist
License Number0202211978
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: