Provider Demographics
NPI:1013415835
Name:SEPULVEDA DIAZ, DAMARIS
Entity Type:Individual
Prefix:
First Name:DAMARIS
Middle Name:
Last Name:SEPULVEDA DIAZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 1201
Mailing Address - Street 2:
Mailing Address - City:LAS PIEDRAS
Mailing Address - State:PR
Mailing Address - Zip Code:00771-1201
Mailing Address - Country:US
Mailing Address - Phone:787-912-7777
Mailing Address - Fax:787-912-7779
Practice Address - Street 1:BO. MONTONES 1
Practice Address - Street 2:PR 183 KM 19.3
Practice Address - City:LAS PIEDRAS
Practice Address - State:PR
Practice Address - Zip Code:00771-1201
Practice Address - Country:US
Practice Address - Phone:787-912-7777
Practice Address - Fax:787-912-7779
Is Sole Proprietor?:No
Enumeration Date:2018-01-26
Last Update Date:2020-01-15
Deactivation Date:2019-09-30
Deactivation Code:
Reactivation Date:2020-01-15
Provider Licenses
StateLicense IDTaxonomies
PR5061183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist