Provider Demographics
NPI:1760789721
Name:RISSELMANN, DIANA (RPH)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:RISSELMANN
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 1:52499 GLENMORE CT
Mailing Address - Street 2:
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-7856
Mailing Address - Country:US
Mailing Address - Phone:574-277-9079
Mailing Address - Fax:574-277-9079
Practice Address - Street 1:110 E MCKINLEY AVE
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-6217
Practice Address - Country:US
Practice Address - Phone:574-255-9677
Practice Address - Fax:574-257-9772
Is Sole Proprietor?:No
Enumeration Date:2011-02-26
Last Update Date:2011-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26015557A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist