Provider Demographics
NPI:1477031425
Name:GLIECK, DIANA
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:GLIECK
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 1:3301 GORDON DR
Mailing Address - Street 2:
Mailing Address - City:SIOUX CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51105-3708
Mailing Address - Country:US
Mailing Address - Phone:712-234-1949
Mailing Address - Fax:712-255-8087
Practice Address - Street 1:3301 GORDON DR
Practice Address - Street 2:
Practice Address - City:SIOUX CITY
Practice Address - State:IA
Practice Address - Zip Code:51105-3708
Practice Address - Country:US
Practice Address - Phone:712-234-1949
Practice Address - Fax:712-255-8087
Is Sole Proprietor?:No
Enumeration Date:2018-08-01
Last Update Date:2018-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA20559183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist