Provider Demographics
NPI:1427653955
Name:BARBOSA, DIANE
Entity type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:
Last Name:BARBOSA
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 1:1109 FANNY ST
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH
Mailing Address - State:NJ
Mailing Address - Zip Code:07201-1303
Mailing Address - Country:US
Mailing Address - Phone:908-477-4385
Mailing Address - Fax:
Practice Address - Street 1:801 NEWARK AVE
Practice Address - Street 2:
Practice Address - City:ELIZABETH
Practice Address - State:NJ
Practice Address - Zip Code:07208-3514
Practice Address - Country:US
Practice Address - Phone:908-820-9301
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-02
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI03098500183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist