Provider Demographics
NPI:1831457027
Name:DIETZLER, FREDERICK G (RPH)
Entity Type:Individual
Prefix:MR
First Name:FREDERICK
Middle Name:G
Last Name:DIETZLER
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 1:605 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:IRONTON
Mailing Address - State:MO
Mailing Address - Zip Code:63650-1006
Mailing Address - Country:US
Mailing Address - Phone:573-546-7915
Mailing Address - Fax:
Practice Address - Street 1:605 N MAIN ST
Practice Address - Street 2:
Practice Address - City:IRONTON
Practice Address - State:MO
Practice Address - Zip Code:63650-1006
Practice Address - Country:US
Practice Address - Phone:573-546-7915
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-25
Last Update Date:2012-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO40265183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist