Provider Demographics
NPI:1225380371
Name:DIAZ, ANTONIO J (RPH)
Entity type:Individual
Prefix:
First Name:ANTONIO
Middle Name:J
Last Name:DIAZ
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 63067
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90063-0067
Mailing Address - Country:US
Mailing Address - Phone:323-262-2354
Mailing Address - Fax:
Practice Address - Street 1:3915 E 2ND ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90063-3613
Practice Address - Country:US
Practice Address - Phone:323-262-2354
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-12
Last Update Date:2012-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH 47901183500000X
NV13947183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist