Provider Demographics
NPI:1124041496
Name:GRISAMORE, DIANE S (PHARMD)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:S
Last Name:GRISAMORE
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7008 COVERED BRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78736-3342
Mailing Address - Country:US
Mailing Address - Phone:512-301-4985
Mailing Address - Fax:
Practice Address - Street 1:2901 MONTOPOLIS DR
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78741-6411
Practice Address - Country:US
Practice Address - Phone:512-389-6510
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX39330183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist