MEDICARE: MRS. MAGDA IVELISSE DIAZ-COLON R.PH.

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	183500000X	Pharmacist	PS23072	FL
2	1835P0018X	Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist	PU5772	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	270969	OTHER	FL	NABP
2	PS23072	OTHER	FL	BOARD OF PHARMACY PHARMACIST LICENSE NUMBER
3	PU5772	OTHER	FL	BOARD OF PHARMACY CONSULTANT PHARMACIST

General Provider Information

NPI Number	:	1619303609
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MAGDA IVELISSE DIAZ-COLON R.PH.

Provider Business Mailing Address
First Line	:	9549 TRULOCK CT
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32817-4718
Country	:	US
Telephone Number	:	407-303-2559
Fax Number	:	407-303-2568

Provider Business Practice Location Address
First Line	:	9549 TRULOCK CT
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32817-4718
Country	:	US
Telephone Number	:	407-303-2559
Fax Number	:	407-303-2768

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/23/2013
Last Update Date	:	09/23/2013

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