Provider Demographics
NPI:1194201160
Name:BLUE, DIANE MICHELLE (RPH)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:MICHELLE
Last Name:BLUE
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 1:1225 SHADOW RIDGE XING
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-3119
Mailing Address - Country:US
Mailing Address - Phone:618-660-6816
Mailing Address - Fax:
Practice Address - Street 1:907 E HIGHWAY 50
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-2856
Practice Address - Country:US
Practice Address - Phone:618-632-9873
Practice Address - Fax:618-632-0729
Is Sole Proprietor?:No
Enumeration Date:2018-07-12
Last Update Date:2018-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051287796183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist