Provider Demographics
NPI:1215697792
Name:DE LA CRUZ, DIEGO (PHARMD)
Entity type:Individual
Prefix:
First Name:DIEGO
Middle Name:
Last Name:DE LA CRUZ
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1005 SMITH ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89108-1561
Mailing Address - Country:US
Mailing Address - Phone:702-498-9306
Mailing Address - Fax:
Practice Address - Street 1:2211 N RAMPART BLVD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-7640
Practice Address - Country:US
Practice Address - Phone:702-256-5200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-23
Last Update Date:2021-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV20928183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist