Provider Demographics
NPI:1336498807
Name:FORDYCE, DIANE S (RPH)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:S
Last Name:FORDYCE
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 1:2200 JUNE PKWY
Mailing Address - Street 2:
Mailing Address - City:ZANESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43701-6377
Mailing Address - Country:US
Mailing Address - Phone:740-450-7859
Mailing Address - Fax:740-450-7943
Practice Address - Street 1:2200 JUNE PKWY
Practice Address - Street 2:
Practice Address - City:ZANESVILLE
Practice Address - State:OH
Practice Address - Zip Code:43701-6377
Practice Address - Country:US
Practice Address - Phone:740-450-7859
Practice Address - Fax:740-450-7943
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-30
Last Update Date:2012-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03313383183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist