Provider Demographics
NPI:1861730079
Name:DIAZ, MILDRED EDITHA (RPH)
Entity type:Individual
Prefix:MS
First Name:MILDRED
Middle Name:EDITHA
Last Name:DIAZ
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 1:1395 6TH ST NW
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33881-2364
Mailing Address - Country:US
Mailing Address - Phone:863-294-8282
Mailing Address - Fax:863-294-8280
Practice Address - Street 1:1395 6TH ST NW
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33881-2364
Practice Address - Country:US
Practice Address - Phone:863-294-8282
Practice Address - Fax:863-294-8280
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-22
Last Update Date:2013-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS26206183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist