Provider Demographics
NPI:1821698929
Name:LEGRANDE, DIANE ADELE (RPH)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:ADELE
Last Name:LEGRANDE
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 1:1980 FREEDOM PKWY
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61571-9468
Mailing Address - Country:US
Mailing Address - Phone:309-745-3476
Mailing Address - Fax:309-745-3487
Practice Address - Street 1:1980 FREEDOM PKWY
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:IL
Practice Address - Zip Code:61571-9468
Practice Address - Country:US
Practice Address - Phone:309-745-3476
Practice Address - Fax:309-745-3487
Is Sole Proprietor?:No
Enumeration Date:2020-10-28
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS11690183500000X
IL051039182183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS11690OtherKANSAS BOARD OF PHARMACY
IL051039182OtherILLINOIS BOARD OF PHARMACY