Provider Demographics
NPI:1689331340
Name:DIAZ, RYAN ANGEL (PHARMACY TECHNICIAN)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:ANGEL
Last Name:DIAZ
Suffix:
Gender:M
Credentials:PHARMACY TECHNICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9104 PALM LN
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92335-5197
Mailing Address - Country:US
Mailing Address - Phone:909-486-9564
Mailing Address - Fax:
Practice Address - Street 1:16910 FOOTHILL BLVD
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92335-3502
Practice Address - Country:US
Practice Address - Phone:909-350-0493
Practice Address - Fax:909-350-2025
Is Sole Proprietor?:No
Enumeration Date:2021-11-17
Last Update Date:2021-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA99278183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician