Provider Demographics
NPI:1093002164
Name:DIEDERICH, CRISTINA N (PHARM D)
Entity Type:Individual
Prefix:MRS
First Name:CRISTINA
Middle Name:N
Last Name:DIEDERICH
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:834 BOUGAINVILLEA ST
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-7609
Mailing Address - Country:US
Mailing Address - Phone:805-543-5071
Mailing Address - Fax:
Practice Address - Street 1:1911 JOHNSON AVE
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-4131
Practice Address - Country:US
Practice Address - Phone:805-542-6339
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-08
Last Update Date:2011-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA49085183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist