Basic Information
| Provider Information | |||||||||
| NPI: | 1558873190 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DIA | ||||||||
| FirstName: | OLIVER | ||||||||
| MiddleName: | CUSTODIO | ||||||||
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| Credential: | RPH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4303 S 289TH PL | ||||||||
| Address2: | |||||||||
| City: | AUBURN | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980012830 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2066124481 | ||||||||
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| Practice Location | |||||||||
| Address1: | 9040 A JACKSON AVE | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984310001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2539682586 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2017 | ||||||||
| LastUpdateDate: | 06/16/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | RPH50999 | WA | N | Pharmacy Service Providers | Pharmacist | 183500000X | RPH44850 | CA | N | Pharmacy Service Providers | Pharmacist | 1835P2201X | WA50999 | WA | Y |
ID Information
| ID | Type | State | Issuer | Description | RPH50999 | 01 | WA | REGISTERED PHARMACIST | OTHER | RPH44850 | 01 | CA | REGISTERED PHARMACIST | OTHER |