Provider Demographics
NPI:1659892214
Name:MACTAVISH, DIANA XIMENA CRUZ
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:XIMENA CRUZ
Last Name:MACTAVISH
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 1:500 N CONGRESS AVE
Mailing Address - Street 2:
Mailing Address - City:LAKE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33403-3802
Mailing Address - Country:US
Mailing Address - Phone:561-352-2381
Mailing Address - Fax:
Practice Address - Street 1:500 N CONGRESS AVE
Practice Address - Street 2:
Practice Address - City:LAKE PARK
Practice Address - State:FL
Practice Address - Zip Code:33403-3802
Practice Address - Country:US
Practice Address - Phone:561-352-2381
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-03
Last Update Date:2022-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS56388183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist