Provider Demographics
NPI:1245632744
Name:DIERKEN, GRETCHEN
Entity type:Individual
Prefix:
First Name:GRETCHEN
Middle Name:
Last Name:DIERKEN
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 1:2510 S RESERVE ST
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-7546
Mailing Address - Country:US
Mailing Address - Phone:406-721-4514
Mailing Address - Fax:
Practice Address - Street 1:2510 S RESERVE ST
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-7546
Practice Address - Country:US
Practice Address - Phone:406-721-4514
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-16
Last Update Date:2014-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTMT33021835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist