Provider Demographics
NPI:1649342973
Name:FORHAN, DIANE ELLEN (RPH)
Entity type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:ELLEN
Last Name:FORHAN
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 WESLEY RD
Mailing Address - Street 2:
Mailing Address - City:GREEN COVE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32043-9572
Mailing Address - Country:US
Mailing Address - Phone:904-673-7099
Mailing Address - Fax:
Practice Address - Street 1:2851 HENLEY RD STE 200
Practice Address - Street 2:
Practice Address - City:GREEN COVE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32043-7206
Practice Address - Country:US
Practice Address - Phone:904-899-6902
Practice Address - Fax:904-291-3288
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2008-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS0021575183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist