Healthcare Provider Details

I. General information

NPI: 1558873190
Provider Name (Legal Business Name): OLIVER CUSTODIO DIA RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2017
Last Update Date: 06/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9040 A JACKSON AVE
TACOMA WA
98431-0001
US

IV. Provider business mailing address

4303 S 289TH PL
AUBURN WA
98001-2830
US

V. Phone/Fax

Practice location:
  • Phone: 253-968-2586
  • Fax:
Mailing address:
  • Phone: 206-612-4481
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRPH50999
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRPH44850
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code1835P2201X
TaxonomyAmbulatory Care Pharmacist
License NumberWA50999
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: