Provider Demographics
NPI:1114325206
Name:DIAMOND, SUSAN RENEE (RPH)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:RENEE
Last Name:DIAMOND
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 1:109 N MARQUETTE RD
Mailing Address - Street 2:
Mailing Address - City:PRAIRIE DU CHIEN
Mailing Address - State:WI
Mailing Address - Zip Code:53821-1512
Mailing Address - Country:US
Mailing Address - Phone:608-326-0581
Mailing Address - Fax:608-326-0586
Practice Address - Street 1:109 N MARQUETTE RD
Practice Address - Street 2:
Practice Address - City:PRAIRIE DU CHIEN
Practice Address - State:WI
Practice Address - Zip Code:53821-1512
Practice Address - Country:US
Practice Address - Phone:608-326-0581
Practice Address - Fax:608-326-0586
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-05
Last Update Date:2014-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI17787-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist