Provider Demographics
NPI:1609152438
Name:DIFFA, NINA
Entity Type:Individual
Prefix:
First Name:NINA
Middle Name:
Last Name:DIFFA
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 1:7777 FOREST LN BLDG A
Mailing Address - Street 2:MS #62
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75230-2571
Mailing Address - Country:US
Mailing Address - Phone:972-661-0835
Mailing Address - Fax:972-386-6502
Practice Address - Street 1:7777 FOREST LN BLDG A
Practice Address - Street 2:MS #62
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75230-2571
Practice Address - Country:US
Practice Address - Phone:972-661-0835
Practice Address - Fax:972-386-6502
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-25
Last Update Date:2011-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX50821183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist