Provider Demographics
NPI:1073655460
Name:LOPEZ, IDALIA DIAZ (RPH)
Entity Type:Individual
Prefix:MRS
First Name:IDALIA
Middle Name:DIAZ
Last Name:LOPEZ
Suffix:
Gender:F
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:CALLE 41J 28 URB VILLA HERMOSA
Mailing Address - Street 2:
Mailing Address - City:CAGUA
Mailing Address - State:PR
Mailing Address - Zip Code:00727
Mailing Address - Country:US
Mailing Address - Phone:787-746-9672
Mailing Address - Fax:787-737-3355
Practice Address - Street 1:CALLE SAN JOSE #4
Practice Address - Street 2:
Practice Address - City:GURABO
Practice Address - State:PR
Practice Address - Zip Code:00778
Practice Address - Country:US
Practice Address - Phone:787-737-3355
Practice Address - Fax:787-737-3355
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR2509183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist