MEDICARE: DIVINE PROVIDENCE INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	333600000X	Pharmacy
2	3336C0003X	Community/Retail Pharmacy	PH03196	NV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	2147176	OTHER		PK

General Provider Information

NPI Number	:	1154733905
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIVINE PROVIDENCE INC

Provider Business Mailing Address
First Line	:	1729 E CHARLESTON BLVD STE F
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89104-1986
Country	:	US
Telephone Number	:	702-778-3072
Fax Number	:	702-778-0512

Provider Business Practice Location Address
First Line	:	1729 E CHARLESTON BLVD STE F
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89104-1986
Country	:	US
Telephone Number	:	702-778-3072
Fax Number	:	702-778-0512

Authorized Official
Title or Position	:	CHIEF PHARMACIST
Name	:	MODUPE IROROBEJE
Credential	:
Telephone Number	:	702-778-3072

Provider Enumeration Date	:	05/28/2014
Last Update Date	:	09/21/2016

Similar Medicare Providers

1558824607 — DIVINE PROVIDENCE INC
Practice Location Address:

1729 E CHARLESTON BLVD STE F
LAS VEGAS, NV
89104-1986

Practice Phone: 954-663-1759
Practice Fax:

1013066125 — MARK F SEVERINO MD
Practice Location Address:

5320 S. RAINBOW BLVD , STE 300
LAS VEGAS, NV
89118-1986

Practice Phone: 702-794-0073
Practice Fax: 702-794-0042

1023956687 — YADIMI RODRIGUEZ MUNOZ
Practice Location Address:

1650 E SAHARA AVE STE 3
LAS VEGAS, NV
89104-3495

Practice Phone: 725-275-8376
Practice Fax: 702-920-8702

1902745177 — BLANCA ROMERO
Practice Location Address:

1650 E SAHARA AVE STE 4
LAS VEGAS, NV
89104-3495

Practice Phone: 702-792-0111
Practice Fax:

1285451906 — DR. MATEO SERRANO DPT
Practice Location Address:

2017 SWEENEY AVE
LAS VEGAS, NV
89104-2035

Practice Phone: 954-618-8327
Practice Fax:

1689538829 — DAPHNE LU
Practice Location Address:

1785 E SAHARA AVE STE 340
LAS VEGAS, NV
89104-3717

Practice Phone: 702-823-4300
Practice Fax:

Directions to “DIVINE PROVIDENCE INC ” Practice Location

Language	Start Address	Practice Location

These directions are for planning purposes only. You may find that construction projects, traffic, or other events may cause road conditions to differ from the map results.

Copyright © 2007-2026 (Powered by Swiss Vault Engine), all rights reserved. HIPAA liability, trademark, document use and software licensing rules apply. All registered trademarks, used in the content, are the property of their owners. Your interactions with this site are in accordance with our Terms of Use and Privacy Policy.