Provider Demographics
NPI:1790003747
Name:VALLE, MAYRA (RPH)
Entity Type:Individual
Prefix:
First Name:MAYRA
Middle Name:
Last Name:VALLE
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2706 PATRICIAN CIR
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34746-3292
Mailing Address - Country:US
Mailing Address - Phone:518-339-0088
Mailing Address - Fax:
Practice Address - Street 1:5000 GRANDVIEW PKWY
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:FL
Practice Address - Zip Code:33837-2300
Practice Address - Country:US
Practice Address - Phone:863-256-1052
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-13
Last Update Date:2010-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS39454183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist