=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407416803
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARIELY DIAZ VARGAS CPH.T
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/18/2019
-----------------------------------------------------
Last Update Date | 06/18/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | CARR 149 KM 57.4 BO TIERRA SANTA
-----------------------------------------------------
City | VILLALBA
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00766
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-847-9393
-----------------------------------------------------
Fax | 787-847-9292
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | URB JAIME L DREW 104 AVE D
-----------------------------------------------------
City | PONCE
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00730
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-847-9393
-----------------------------------------------------
Fax | 787-847-9292
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183700000X
-----------------------------------------------------
Taxonomy Name | Pharmacy Technician
-----------------------------------------------------
License Number | 4119
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------