Provider Demographics
NPI:1164546685
Name:DIBACCO, DANIEL (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:
Last Name:DIBACCO
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:136 PEACHTREE MEMORIAL DR NW
Mailing Address - Street 2:PENNYSLVANIA #7
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30309-1096
Mailing Address - Country:US
Mailing Address - Phone:404-808-2722
Mailing Address - Fax:
Practice Address - Street 1:2200 ROSWELL RD
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30062-2983
Practice Address - Country:US
Practice Address - Phone:770-973-7337
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA021517183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist