Provider Demographics
NPI:1710576970
Name:CLARK, DIANE ADELE
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:ADELE
Last Name:CLARK
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 1:925 10TH ST
Mailing Address - Street 2:
Mailing Address - City:FLORESVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78114-1851
Mailing Address - Country:US
Mailing Address - Phone:830-393-8098
Mailing Address - Fax:
Practice Address - Street 1:925 10TH ST
Practice Address - Street 2:
Practice Address - City:FLORESVILLE
Practice Address - State:TX
Practice Address - Zip Code:78114-1851
Practice Address - Country:US
Practice Address - Phone:830-393-8098
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-12
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX187925183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician