Provider Demographics
NPI:1356940860
Name:GOMES, DIANE MEDEIROS (PHARMD)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:MEDEIROS
Last Name:GOMES
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:DIANE
Other - Middle Name:
Other - Last Name:MEDEIROS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHARMD
Mailing Address - Street 1:150 RYAN ST
Mailing Address - Street 2:
Mailing Address - City:NEW BEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02740-1473
Mailing Address - Country:US
Mailing Address - Phone:774-930-1564
Mailing Address - Fax:
Practice Address - Street 1:345 BLACKSTONE BLVD
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02906-4800
Practice Address - Country:US
Practice Address - Phone:401-455-6316
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-26
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA25778183500000X
RIRPH04561183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MARPH04561OtherMA LICENSE