Provider Demographics
NPI:1609915859
Name:DIAZ, WANDA I
Entity Type:Individual
Prefix:MRS
First Name:WANDA
Middle Name:I
Last Name:DIAZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:CALLE 1 B 6
Mailing Address - Street 2:VILLAS DEL MADRIGAL
Mailing Address - City:CAROLINA
Mailing Address - State:PR
Mailing Address - Zip Code:00987-0000
Mailing Address - Country:US
Mailing Address - Phone:787-769-8224
Mailing Address - Fax:
Practice Address - Street 1:CALLE 1 B 6 VILLAS DEL MADRIGAL
Practice Address - Street 2:
Practice Address - City:CAROLINA
Practice Address - State:PR
Practice Address - Zip Code:00987
Practice Address - Country:US
Practice Address - Phone:787-769-8224
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR005010183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR2275625OtherLICENSE