Provider Demographics
NPI:1508149873
Name:DIEGO, MARYSOL (RPH, PHARMD)
Entity Type:Individual
Prefix:
First Name:MARYSOL
Middle Name:
Last Name:DIEGO
Suffix:
Gender:F
Credentials:RPH, PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:704 HERO WAY
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:07109-5338
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6012 KENNEDY BLVD W
Practice Address - Street 2:
Practice Address - City:WEST NEW YORK
Practice Address - State:NJ
Practice Address - Zip Code:07093-1447
Practice Address - Country:US
Practice Address - Phone:201-869-9004
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-23
Last Update Date:2011-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI02782300183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist