Provider Demographics
NPI:1689189987
Name:DIMOND, CONSTANCE REBECCA
Entity Type:Individual
Prefix:
First Name:CONSTANCE
Middle Name:REBECCA
Last Name:DIMOND
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 1:251 SOUTH HWY 97
Mailing Address - Street 2:
Mailing Address - City:SAND SPRINGS
Mailing Address - State:OK
Mailing Address - Zip Code:74063
Mailing Address - Country:US
Mailing Address - Phone:918-246-9570
Mailing Address - Fax:
Practice Address - Street 1:251 SOUTH HWY 97
Practice Address - Street 2:
Practice Address - City:SAND SPRINGS
Practice Address - State:OK
Practice Address - Zip Code:74063
Practice Address - Country:US
Practice Address - Phone:918-246-9570
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-08
Last Update Date:2017-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK15842183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK15842OtherSTATE LICENSE