Provider Demographics
NPI:1659654739
Name:DIEPENBROCK, ERIN NICOLE (RPH)
Entity Type:Individual
Prefix:MRS
First Name:ERIN
Middle Name:NICOLE
Last Name:DIEPENBROCK
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 1:920 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63366-1746
Mailing Address - Country:US
Mailing Address - Phone:636-379-2636
Mailing Address - Fax:636-379-2640
Practice Address - Street 1:920 N MAIN ST
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63366-1746
Practice Address - Country:US
Practice Address - Phone:636-379-2636
Practice Address - Fax:636-379-2640
Is Sole Proprietor?:No
Enumeration Date:2011-09-24
Last Update Date:2011-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004033688183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist