Provider Demographics
NPI:1487249629
Name:SETH, DIANE JOY
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:JOY
Last Name:SETH
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 1:337 WATSON ST
Mailing Address - Street 2:
Mailing Address - City:COOPERSVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49404-1017
Mailing Address - Country:US
Mailing Address - Phone:231-750-7217
Mailing Address - Fax:
Practice Address - Street 1:4542 KENOWA AVE SW
Practice Address - Street 2:
Practice Address - City:GRANDVILLE
Practice Address - State:MI
Practice Address - Zip Code:49418-9523
Practice Address - Country:US
Practice Address - Phone:616-667-9713
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-09
Last Update Date:2021-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5303009856183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician