Provider Demographics
NPI:1568753218
Name:RACKHAM NIELSON, DIANA L (RPH)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:L
Last Name:RACKHAM NIELSON
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:DIANA
Other - Middle Name:L
Other - Last Name:NIELSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RPH
Mailing Address - Street 1:731 POLELINE RD
Mailing Address - Street 2:ATTENTION PHARMACY
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-3036
Mailing Address - Country:US
Mailing Address - Phone:208-736-1725
Mailing Address - Fax:208-736-7318
Practice Address - Street 1:731 POLELINE RD
Practice Address - Street 2:ATTENTION PHARMACY
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-3036
Practice Address - Country:US
Practice Address - Phone:208-736-1725
Practice Address - Fax:208-736-7318
Is Sole Proprietor?:No
Enumeration Date:2011-04-28
Last Update Date:2011-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP4507183500000X
NV1052183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist