Provider Demographics
NPI:1518213206
Name:MEDINA, DIEGO JR (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:DIEGO
Middle Name:
Last Name:MEDINA
Suffix:JR
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 VALLEY ST APT 244
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:MA
Mailing Address - Zip Code:02149-2035
Mailing Address - Country:US
Mailing Address - Phone:415-629-2008
Mailing Address - Fax:
Practice Address - Street 1:590 FELLSWAY
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155-4925
Practice Address - Country:US
Practice Address - Phone:781-391-2668
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-31
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPH241523183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist