Provider Demographics
NPI:1073079281
Name:DIETZ, SPENCER LOUIS (PHARMD, RPH)
Entity Type:Individual
Prefix:
First Name:SPENCER
Middle Name:LOUIS
Last Name:DIETZ
Suffix:
Gender:M
Credentials:PHARMD, RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3270 E 17TH ST # 130
Mailing Address - Street 2:
Mailing Address - City:AMMON
Mailing Address - State:ID
Mailing Address - Zip Code:83406-6758
Mailing Address - Country:US
Mailing Address - Phone:208-569-5839
Mailing Address - Fax:
Practice Address - Street 1:3250 E 17TH ST
Practice Address - Street 2:
Practice Address - City:AMMON
Practice Address - State:ID
Practice Address - Zip Code:83406-6758
Practice Address - Country:US
Practice Address - Phone:208-552-7677
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-12
Last Update Date:2019-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP5827183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist