Provider Demographics
NPI:1114356771
Name:VILLALBA, DIEGO ANDRES (PHARMD)
Entity Type:Individual
Prefix:
First Name:DIEGO
Middle Name:ANDRES
Last Name:VILLALBA
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8520 75TH AVE
Mailing Address - Street 2:
Mailing Address - City:SEMINOLE
Mailing Address - State:FL
Mailing Address - Zip Code:33777-4434
Mailing Address - Country:US
Mailing Address - Phone:575-590-4397
Mailing Address - Fax:
Practice Address - Street 1:10121 SEMINOLE BLVD
Practice Address - Street 2:
Practice Address - City:SEMINOLE
Practice Address - State:FL
Practice Address - Zip Code:33772-2543
Practice Address - Country:US
Practice Address - Phone:727-398-7308
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-04
Last Update Date:2013-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS51055183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist