Provider Demographics
NPI:1407416803
Name:DIAZ VARGAS, MARIELY (CPHT)
Entity Type:Individual
Prefix:MISS
First Name:MARIELY
Middle Name:
Last Name:DIAZ VARGAS
Suffix:
Gender:F
Credentials:CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:URB JAIME L DREW
Mailing Address - Street 2:104 AVE D
Mailing Address - City:PONCE
Mailing Address - State:PR
Mailing Address - Zip Code:00730
Mailing Address - Country:US
Mailing Address - Phone:787-847-9393
Mailing Address - Fax:787-847-9292
Practice Address - Street 1:CARR 149 KM 57.4 BO TIERRA SANTA
Practice Address - Street 2:
Practice Address - City:VILLALBA
Practice Address - State:PR
Practice Address - Zip Code:00766
Practice Address - Country:US
Practice Address - Phone:787-847-9393
Practice Address - Fax:787-847-9292
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-18
Last Update Date:2019-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR4119183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183700000XPharmacy Service ProvidersPharmacy TechnicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR4119OtherLICENSE