Provider Demographics
NPI:1083937684
Name:DIAZ, TOMAS (RPH)
Entity Type:Individual
Prefix:
First Name:TOMAS
Middle Name:
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 1:1805 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-1761
Mailing Address - Country:US
Mailing Address - Phone:631-231-4960
Mailing Address - Fax:631-980-4279
Practice Address - Street 1:1805 5TH AVE
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-1761
Practice Address - Country:US
Practice Address - Phone:631-231-4960
Practice Address - Fax:631-980-4279
Is Sole Proprietor?:No
Enumeration Date:2010-03-10
Last Update Date:2010-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY36707183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist