Provider Demographics
NPI:1568980597
Name:KENNER-STAVES, DIANNA N (PHARMD)
Entity Type:Individual
Prefix:
First Name:DIANNA
Middle Name:N
Last Name:KENNER-STAVES
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HARRIS TEETER PHARMACY 324
Mailing Address - Street 2:15501 ANNAPOLIS RD
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20715
Mailing Address - Country:US
Mailing Address - Phone:301-383-2945
Mailing Address - Fax:301-383-2948
Practice Address - Street 1:15501 ANNAPOLIS RD
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20715-3046
Practice Address - Country:US
Practice Address - Phone:301-383-2945
Practice Address - Fax:301-383-2948
Is Sole Proprietor?:No
Enumeration Date:2017-08-30
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD24632183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist