Provider Demographics
NPI:1922540137
Name:DIAZ, RAENEISSA (PHARMD)
Entity Type:Individual
Prefix:
First Name:RAENEISSA
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 1:19315 YELLOW CLOVER DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33647-3669
Mailing Address - Country:US
Mailing Address - Phone:813-431-2485
Mailing Address - Fax:
Practice Address - Street 1:19315 YELLOW CLOVER DR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33647-3669
Practice Address - Country:US
Practice Address - Phone:813-431-2485
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-07
Last Update Date:2016-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS46890183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist