Provider Demographics
NPI:1316566151
Name:DIETZEL, BRYAN (RPH)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:
Last Name:DIETZEL
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:675 E SUNSET BLVD
Mailing Address - Street 2:
Mailing Address - City:CELINA
Mailing Address - State:TX
Mailing Address - Zip Code:75009-4017
Mailing Address - Country:US
Mailing Address - Phone:972-382-3989
Mailing Address - Fax:
Practice Address - Street 1:675 E SUNSET BLVD
Practice Address - Street 2:
Practice Address - City:CELINA
Practice Address - State:TX
Practice Address - Zip Code:75009-4017
Practice Address - Country:US
Practice Address - Phone:972-382-3989
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-12
Last Update Date:2020-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX38050183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist