Provider Demographics
NPI:1841895885
Name:BANOUB, DIANA
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:BANOUB
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 1:7710 CHIPPEWA RD
Mailing Address - Street 2:
Mailing Address - City:BRECKSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44141-2312
Mailing Address - Country:US
Mailing Address - Phone:440-546-1655
Mailing Address - Fax:
Practice Address - Street 1:7710 CHIPPEWA RD
Practice Address - Street 2:
Practice Address - City:BRECKSVILLE
Practice Address - State:OH
Practice Address - Zip Code:44141-2312
Practice Address - Country:US
Practice Address - Phone:440-546-1655
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-30
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03233372183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1954776039Medicaid