Provider Demographics
NPI:1245882257
Name:DE DIOS, CAROL JEAN (RPH)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:JEAN
Last Name:DE DIOS
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 SAN MIGUEL CT
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79705-2225
Mailing Address - Country:US
Mailing Address - Phone:661-204-7305
Mailing Address - Fax:
Practice Address - Street 1:1500 SAN MIGUEL CT
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79705-2225
Practice Address - Country:US
Practice Address - Phone:661-204-7305
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-10
Last Update Date:2019-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA43891183500000X
OR8405183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR8405Medicaid