Provider Demographics
NPI:1215223052
Name:DIBBERT, ALLA A (BS)
Entity Type:Individual
Prefix:
First Name:ALLA
Middle Name:A
Last Name:DIBBERT
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5659 PHILLIPS BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27104-3320
Mailing Address - Country:US
Mailing Address - Phone:336-245-8995
Mailing Address - Fax:
Practice Address - Street 1:3186 PETERS CREEK PKWY
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27127-4755
Practice Address - Country:US
Practice Address - Phone:336-788-1813
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-20
Last Update Date:2011-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCNC16809183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist