Provider Demographics
NPI:1821367566
Name:DIESTLER, THOMAS (RPH)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:DIESTLER
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 E SUNSET DR
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53189-7603
Mailing Address - Country:US
Mailing Address - Phone:262-542-3981
Mailing Address - Fax:
Practice Address - Street 1:221 E SUNSET DR
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53189-7603
Practice Address - Country:US
Practice Address - Phone:262-542-3981
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-27
Last Update Date:2011-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9499183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist