Provider Demographics
NPI:1902369119
Name:PARK, DIANNE M
Entity Type:Individual
Prefix:
First Name:DIANNE
Middle Name:M
Last Name:PARK
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 1:2514 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80504-9740
Mailing Address - Country:US
Mailing Address - Phone:303-774-9419
Mailing Address - Fax:303-774-9427
Practice Address - Street 1:2514 MAIN ST
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80504-9740
Practice Address - Country:US
Practice Address - Phone:303-774-9419
Practice Address - Fax:303-774-9427
Is Sole Proprietor?:No
Enumeration Date:2019-04-13
Last Update Date:2019-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO13625183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist