Provider Demographics
NPI:1396824777
Name:DEAVILA, ADA J (RPH)
Entity Type:Individual
Prefix:MRS
First Name:ADA
Middle Name:J
Last Name:DEAVILA
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4622 SW 82ND CT
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33155-5447
Mailing Address - Country:US
Mailing Address - Phone:305-227-9915
Mailing Address - Fax:
Practice Address - Street 1:3275 CORAL WAY
Practice Address - Street 2:
Practice Address - City:CORAL GABLES
Practice Address - State:FL
Practice Address - Zip Code:33145-2233
Practice Address - Country:US
Practice Address - Phone:305-460-8941
Practice Address - Fax:305-460-8942
Is Sole Proprietor?:No
Enumeration Date:2006-11-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS14415183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0556050734Medicare ID - Type Unspecified