Provider Demographics
NPI:1043810625
Name:PRUITT, DIANE MARIE (RPH)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:MARIE
Last Name:PRUITT
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 1:1820 SHORE LINE DR
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34748-8148
Mailing Address - Country:US
Mailing Address - Phone:352-636-5158
Mailing Address - Fax:
Practice Address - Street 1:2501 CITRUS BLVD
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-7204
Practice Address - Country:US
Practice Address - Phone:352-326-4044
Practice Address - Fax:352-326-2860
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-31
Last Update Date:2020-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS30320183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist