Provider Demographics
NPI:1356439822
Name:DIAZ, MYRNA S (LIC)
Entity Type:Individual
Prefix:
First Name:MYRNA
Middle Name:S
Last Name:DIAZ
Suffix:
Gender:F
Credentials:LIC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:CALLE PALMA 1419
Mailing Address - Street 2:HACIENDA BORINQUEN
Mailing Address - City:CAGUAS
Mailing Address - State:PR
Mailing Address - Zip Code:00725
Mailing Address - Country:US
Mailing Address - Phone:787-286-0577
Mailing Address - Fax:
Practice Address - Street 1:CALLE PALMA 1419
Practice Address - Street 2:HACIENDA BORINQUEN
Practice Address - City:CAGUAS
Practice Address - State:PR
Practice Address - Zip Code:00725
Practice Address - Country:US
Practice Address - Phone:787-286-0577
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR4737183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist