Provider Demographics
NPI:1942817416
Name:DIAZ-LATORRE, EDGARDO L (PHARMD)
Entity Type:Individual
Prefix:
First Name:EDGARDO
Middle Name:L
Last Name:DIAZ-LATORRE
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 W VINE ST
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34741-4168
Mailing Address - Country:US
Mailing Address - Phone:407-847-5252
Mailing Address - Fax:407-870-9238
Practice Address - Street 1:1111 W VINE ST
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-4168
Practice Address - Country:US
Practice Address - Phone:407-847-5252
Practice Address - Fax:407-870-9238
Is Sole Proprietor?:No
Enumeration Date:2020-09-28
Last Update Date:2020-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS51343183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist