Provider Demographics
NPI:1851994248
Name:DIAZ, ANDREA (PHARMD)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:DIAZ
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:704 W DR MARTIN LUTHER KING JR BLVD
Mailing Address - Street 2:
Mailing Address - City:SEFFNER
Mailing Address - State:FL
Mailing Address - Zip Code:33584-4534
Mailing Address - Country:US
Mailing Address - Phone:813-681-4431
Mailing Address - Fax:
Practice Address - Street 1:704 W DR MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:SEFFNER
Practice Address - State:FL
Practice Address - Zip Code:33584-4534
Practice Address - Country:US
Practice Address - Phone:813-681-4431
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-18
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS45065183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist