Provider Demographics
NPI:1356045496
Name:SMITH, DIANE LINDA
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:LINDA
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DIANE
Other - Middle Name:LINDA
Other - Last Name:COLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:117 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FREDERICKTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:43019-1225
Mailing Address - Country:US
Mailing Address - Phone:740-694-5717
Mailing Address - Fax:740-694-1486
Practice Address - Street 1:117 S MAIN ST
Practice Address - Street 2:
Practice Address - City:FREDERICKTOWN
Practice Address - State:OH
Practice Address - Zip Code:43019-1225
Practice Address - Country:US
Practice Address - Phone:740-694-5717
Practice Address - Fax:740-694-1486
Is Sole Proprietor?:No
Enumeration Date:2023-03-30
Last Update Date:2023-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH09200305183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician