Provider Demographics
NPI:1316074263
Name:DIETRICK, NANCY ELLEN (RPH)
Entity type:Individual
Prefix:
First Name:NANCY
Middle Name:ELLEN
Last Name:DIETRICK
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 1:60 LEXINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:HAMBURG
Mailing Address - State:NY
Mailing Address - Zip Code:14075-6622
Mailing Address - Country:US
Mailing Address - Phone:716-648-2584
Mailing Address - Fax:
Practice Address - Street 1:40 CENTRE DR
Practice Address - Street 2:
Practice Address - City:ORCHARD PARK
Practice Address - State:NY
Practice Address - Zip Code:14127-4100
Practice Address - Country:US
Practice Address - Phone:716-667-7500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY032671183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist