Provider Demographics
NPI:1396469409
Name:PEDRAZA, DIEGO
Entity type:Individual
Prefix:
First Name:DIEGO
Middle Name:
Last Name:PEDRAZA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9940 YAMATO RD
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33434-5538
Mailing Address - Country:US
Mailing Address - Phone:561-488-9838
Mailing Address - Fax:
Practice Address - Street 1:9940 YAMATO RD
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33434-5538
Practice Address - Country:US
Practice Address - Phone:561-488-9838
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-03
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS47139183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty