Provider Demographics
NPI:1396349569
Name:HASSELL-LATHAM, DIANE MARIE (RPH)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:MARIE
Last Name:HASSELL-LATHAM
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 1:283 SW BAYA DR
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32025-5227
Mailing Address - Country:US
Mailing Address - Phone:386-755-2770
Mailing Address - Fax:386-755-0421
Practice Address - Street 1:283 SW BAYA DR
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32025-5227
Practice Address - Country:US
Practice Address - Phone:386-755-2770
Practice Address - Fax:386-755-0421
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-27
Last Update Date:2020-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS030272183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist