Provider Demographics
NPI:1790832103
Name:DIAZ, MARILIS
Entity Type:Individual
Prefix:
First Name:MARILIS
Middle Name:
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 1:1271 SW 124TH CT APT C
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33184-2352
Mailing Address - Country:US
Mailing Address - Phone:305-551-8806
Mailing Address - Fax:
Practice Address - Street 1:161 NW 29TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33127-3929
Practice Address - Country:US
Practice Address - Phone:305-571-5121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL140103545342669183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician