Provider Demographics
NPI:1689883530
Name:FAIDLEY, DIANNA MARIE (RPH, CDM)
Entity Type:Individual
Prefix:MRS
First Name:DIANNA
Middle Name:MARIE
Last Name:FAIDLEY
Suffix:
Gender:F
Credentials:RPH, CDM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:815 E. JUAN SANCHEZ BLVD.
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS
Mailing Address - State:AZ
Mailing Address - Zip Code:85349
Mailing Address - Country:US
Mailing Address - Phone:928-344-4113
Mailing Address - Fax:928-373-5767
Practice Address - Street 1:815 E. JUAN SANCHEZ BLVD.
Practice Address - Street 2:
Practice Address - City:SAN LUIS
Practice Address - State:AZ
Practice Address - Zip Code:85349
Practice Address - Country:US
Practice Address - Phone:928-373-5757
Practice Address - Fax:928-373-5757
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ8594183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist