MEDICARE: MRS. MARIA L DEJESUS DIAZ

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	183700000X	Pharmacy Technician	3384	PR

General Provider Information

NPI Number	:	1669714317
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MARIA L DEJESUS DIAZ

Provider Business Mailing Address
First Line	:	158 CALLE 11
Second Line	:	BDA. ROOSEVELT
City	:	SAN LORENZO
State	:	PR
Zip	:	00754-3112
Country	:	US
Telephone Number	:	787-736-4845
Fax Number	:	787-736-4020

Provider Business Practice Location Address
First Line	:	158 CALLE 11
Second Line	:	BDA. ROOSEVELT
City	:	SAN LORENZO
State	:	PR
Zip	:	00754-3112
Country	:	US
Telephone Number	:	787-736-4845
Fax Number	:	787-736-4020

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

Provider Enumeration Date	:	03/20/2013
Last Update Date	:	03/20/2013

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