Provider Demographics
NPI:1225318744
Name:BARTZ, DIANNE BUTKE
Entity Type:Individual
Prefix:
First Name:DIANNE
Middle Name:BUTKE
Last Name:BARTZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3603 FOXBOROUGH LN
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61114-7062
Mailing Address - Country:US
Mailing Address - Phone:815-637-1531
Mailing Address - Fax:
Practice Address - Street 1:3336 11TH ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61109-2206
Practice Address - Country:US
Practice Address - Phone:815-394-0357
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-29
Last Update Date:2011-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.033505183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist