Provider Demographics
NPI:1669764478
Name:GRIBBIN, DIANE C (RPH)
Entity type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:C
Last Name:GRIBBIN
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 1:109 NORTHWEST DR
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06795-2044
Mailing Address - Country:US
Mailing Address - Phone:860-274-9756
Mailing Address - Fax:
Practice Address - Street 1:1271 MAIN ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:CT
Practice Address - Zip Code:06795-3107
Practice Address - Country:US
Practice Address - Phone:860-274-9191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-11
Last Update Date:2011-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT7624183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT7624OtherPHARMACY LICENSE