Provider Demographics
NPI:1043230949
Name:WACKEL, DIANA LYNN (RPH)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:LYNN
Last Name:WACKEL
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 1:111 WASHINGTON AVE NW
Mailing Address - Street 2:
Mailing Address - City:WAGNER
Mailing Address - State:SD
Mailing Address - Zip Code:57380
Mailing Address - Country:US
Mailing Address - Phone:605-384-3621
Mailing Address - Fax:605-384-3293
Practice Address - Street 1:111 WASHINGTON AVE NW
Practice Address - Street 2:
Practice Address - City:WAGNER
Practice Address - State:SD
Practice Address - Zip Code:57380
Practice Address - Country:US
Practice Address - Phone:605-384-3621
Practice Address - Fax:605-384-3293
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD3833183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5540030Medicaid