Provider Demographics
NPI:1235240649
Name:DIAZ, LAWRENCE A (RPH)
Entity Type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:A
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 1:3914 SW 102ND WAY
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32607-4658
Mailing Address - Country:US
Mailing Address - Phone:352-332-0649
Mailing Address - Fax:352-331-5041
Practice Address - Street 1:220 N MAIN ST
Practice Address - Street 2:
Practice Address - City:TRENTON
Practice Address - State:FL
Practice Address - Zip Code:32693-3438
Practice Address - Country:US
Practice Address - Phone:352-463-2240
Practice Address - Fax:352-463-1645
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS12049183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPS12049OtherLICENSE NUMBER