Provider Demographics
NPI:1558873190
Name:DIA, OLIVER CUSTODIO (RPH)
Entity Type:Individual
Prefix:
First Name:OLIVER
Middle Name:CUSTODIO
Last Name:DIA
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4303 S 289TH PL
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:WA
Mailing Address - Zip Code:98001-2830
Mailing Address - Country:US
Mailing Address - Phone:206-612-4481
Mailing Address - Fax:
Practice Address - Street 1:9040 A JACKSON AVE
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98431-0001
Practice Address - Country:US
Practice Address - Phone:253-968-2586
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-03
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARPH50999183500000X
CARPH44850183500000X
WAWA509991835P2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P2201XPharmacy Service ProvidersPharmacistAmbulatory Care
No183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WARPH50999OtherREGISTERED PHARMACIST
CARPH44850OtherREGISTERED PHARMACIST