Provider Demographics
NPI:1003899956
Name:DIETZLER, JUDITH ANN (RPH)
Entity Type:Individual
Prefix:MRS
First Name:JUDITH
Middle Name:ANN
Last Name:DIETZLER
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 1:928 DORNE DR
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:MO
Mailing Address - Zip Code:63021-6876
Mailing Address - Country:US
Mailing Address - Phone:636-861-3447
Mailing Address - Fax:317-768-8871
Practice Address - Street 1:1035 BELLEVUE AVE
Practice Address - Street 2:CLAYTON HEALTH SERVICES PHARMACY
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63117-1854
Practice Address - Country:US
Practice Address - Phone:314-768-8870
Practice Address - Fax:314-768-8871
Is Sole Proprietor?:No
Enumeration Date:2005-11-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO40320183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist