Provider Demographics
NPI:1619303609
Name:DIAZ-COLON, MAGDA IVELISSE (RPH)
Entity Type:Individual
Prefix:MRS
First Name:MAGDA
Middle Name:IVELISSE
Last Name:DIAZ-COLON
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:MRS
Other - First Name:MAGDA
Other - Middle Name:IVELISSE
Other - Last Name:COLON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RPH
Mailing Address - Street 1:9549 TRULOCK CT
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32817-4718
Mailing Address - Country:US
Mailing Address - Phone:407-303-2559
Mailing Address - Fax:407-303-2568
Practice Address - Street 1:9549 TRULOCK CT
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32817-4718
Practice Address - Country:US
Practice Address - Phone:407-303-2559
Practice Address - Fax:407-303-2768
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-23
Last Update Date:2013-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS23072183500000X
FLPU57721835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL270969OtherNABP
FLPS23072OtherBOARD OF PHARMACY PHARMACIST LICENSE NUMBER
FLPU5772OtherBOARD OF PHARMACY CONSULTANT PHARMACIST