Provider Demographics
NPI:1598105264
Name:ERICKSON, DIANNA LYNN (RPH)
Entity Type:Individual
Prefix:
First Name:DIANNA
Middle Name:LYNN
Last Name:ERICKSON
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 1:14700 410TH ST SW
Mailing Address - Street 2:
Mailing Address - City:FERTILE
Mailing Address - State:MN
Mailing Address - Zip Code:56540-9116
Mailing Address - Country:US
Mailing Address - Phone:218-945-6293
Mailing Address - Fax:218-281-6742
Practice Address - Street 1:14700 410TH ST SW
Practice Address - Street 2:
Practice Address - City:FERTILE
Practice Address - State:MN
Practice Address - Zip Code:56540-9116
Practice Address - Country:US
Practice Address - Phone:218-945-6293
Practice Address - Fax:218-281-6742
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-26
Last Update Date:2013-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN111879183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist