Provider Demographics
NPI:1700389996
Name:SERVEDIO, DIANE (RPH)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:SERVEDIO
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 1:25 LINCOLN DR
Mailing Address - Street 2:
Mailing Address - City:GALES FERRY
Mailing Address - State:CT
Mailing Address - Zip Code:06335-1626
Mailing Address - Country:US
Mailing Address - Phone:860-464-2605
Mailing Address - Fax:
Practice Address - Street 1:172 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MERIDEN
Practice Address - State:CT
Practice Address - Zip Code:06451-4104
Practice Address - Country:US
Practice Address - Phone:203-235-6305
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-14
Last Update Date:2018-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0006946183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist