Provider Demographics
NPI:1275587867
Name:FLYING DIAMOND PHARMACY LLC
Entity Type:Organization
Organization Name:FLYING DIAMOND PHARMACY LLC
Other - Org Name:FLYING DIAMOND PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER, OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:WANDA
Authorized Official - Middle Name:AVERA
Authorized Official - Last Name:HILL
Authorized Official - Suffix:
Authorized Official - Credentials:CPHT
Authorized Official - Phone:775-787-1144
Mailing Address - Street 1:6140 MAE ANNE AVE STE 1B
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89523-4707
Mailing Address - Country:US
Mailing Address - Phone:775-787-1144
Mailing Address - Fax:775-787-1143
Practice Address - Street 1:6140 MAE ANNE AVE STE 1B
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89523-4707
Practice Address - Country:US
Practice Address - Phone:775-787-1144
Practice Address - Fax:775-787-1143
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-19
Last Update Date:2015-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPH021143336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100509084Medicaid
NV100509085Medicaid