Provider Demographics
NPI:1043622913
Name:LIZAMA, DIEM NGUYEN (RPH,PHARMD)
Entity Type:Individual
Prefix:
First Name:DIEM
Middle Name:NGUYEN
Last Name:LIZAMA
Suffix:
Gender:F
Credentials:RPH,PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8001 LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60077-3695
Mailing Address - Country:US
Mailing Address - Phone:800-553-7359
Mailing Address - Fax:
Practice Address - Street 1:8001 LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60077-3695
Practice Address - Country:US
Practice Address - Phone:800-553-7359
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-28
Last Update Date:2014-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK15070183500000X
TX50631183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist