Provider Demographics
NPI:1568291573
Name:DIETRICH, MALENA (PHARM D)
Entity type:Individual
Prefix:
First Name:MALENA
Middle Name:
Last Name:DIETRICH
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3408 BOBWHITE LN
Mailing Address - Street 2:
Mailing Address - City:WEST PLAINS
Mailing Address - State:MO
Mailing Address - Zip Code:65775-5174
Mailing Address - Country:US
Mailing Address - Phone:417-293-9692
Mailing Address - Fax:
Practice Address - Street 1:605 PAWNEE ST
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MO
Practice Address - Zip Code:64735-2757
Practice Address - Country:US
Practice Address - Phone:660-885-3034
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-29
Last Update Date:2024-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2024030011183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist