Provider Demographics
NPI:1467854182
Name:KOETZ, DIANE (RPH)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:KOETZ
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 1:954 154TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:HAM LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55304-5563
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12480 ABERDEEN ST NE
Practice Address - Street 2:
Practice Address - City:BLAINE
Practice Address - State:MN
Practice Address - Zip Code:55449-4721
Practice Address - Country:US
Practice Address - Phone:763-862-6596
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-25
Last Update Date:2022-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDRPH5666183500000X
MN121785183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist