Provider Demographics
NPI:1154862654
Name:GRULLON TAVARES, DIANA
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:GRULLON TAVARES
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 1:2240 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10035-2904
Mailing Address - Country:US
Mailing Address - Phone:212-360-1757
Mailing Address - Fax:917-675-7055
Practice Address - Street 1:2240 3RD AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10035-2904
Practice Address - Country:US
Practice Address - Phone:212-360-1757
Practice Address - Fax:917-675-7055
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-16
Last Update Date:2017-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY035341183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist