Provider Demographics
NPI:1134763733
Name:MAYA, IDERIS
Entity type:Individual
Prefix:
First Name:IDERIS
Middle Name:
Last Name:MAYA
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 1:8346 NW 10TH ST APT 4F
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33126-2720
Mailing Address - Country:US
Mailing Address - Phone:786-663-5829
Mailing Address - Fax:
Practice Address - Street 1:15885 SW 88TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33196-1003
Practice Address - Country:US
Practice Address - Phone:305-388-1746
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-06
Last Update Date:2019-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS39164183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Multi-Specialty