Provider Demographics
NPI:1598229692
Name:JUAREZ VIVEROS, DIEGO ARMANDO
Entity Type:Individual
Prefix:
First Name:DIEGO
Middle Name:ARMANDO
Last Name:JUAREZ VIVEROS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5712 CARTWRIGHT AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:91601-2112
Mailing Address - Country:US
Mailing Address - Phone:805-890-7963
Mailing Address - Fax:
Practice Address - Street 1:5652 VINELAND AVE STE 102
Practice Address - Street 2:
Practice Address - City:NORTH HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:91601-2062
Practice Address - Country:US
Practice Address - Phone:818-508-8665
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-23
Last Update Date:2019-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH72716183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist