Provider Demographics
NPI:1588720585
Name:FARMACIA DIAZ CORP
Entity type:Organization
Organization Name:FARMACIA DIAZ CORP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:JAVIER
Authorized Official - Middle Name:
Authorized Official - Last Name:MIRADA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-857-7954
Mailing Address - Street 1:PO BOX 959
Mailing Address - Street 2:
Mailing Address - City:BARRANQUITAS
Mailing Address - State:PR
Mailing Address - Zip Code:00794-0959
Mailing Address - Country:US
Mailing Address - Phone:787-857-7954
Mailing Address - Fax:787-857-5249
Practice Address - Street 1:CARRETERA 152 KM 2.8
Practice Address - Street 2:BARRIO QUEBRADILLAS
Practice Address - City:BARRANQUITAS
Practice Address - State:PR
Practice Address - Zip Code:00794
Practice Address - Country:US
Practice Address - Phone:787-857-7954
Practice Address - Fax:787-857-5249
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-28
Last Update Date:2012-08-03
Deactivation Date:2007-07-17
Deactivation Code:
Reactivation Date:2007-08-08
Provider Licenses
StateLicense IDTaxonomies
333600000X
PR13F21083336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4024167OtherNCPDP PROVIDER IDENTIFICATION NUMBER
PR5234100001Medicaid