Provider Demographics
NPI:1992115695
Name:DIETRICH, PATRICIA
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:
Last Name:DIETRICH
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 1:146 TWIN POINT DR
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:LA
Mailing Address - Zip Code:71006-8701
Mailing Address - Country:US
Mailing Address - Phone:318-349-6669
Mailing Address - Fax:
Practice Address - Street 1:302 E PALMETTO
Practice Address - Street 2:
Practice Address - City:PLAIN DEALING
Practice Address - State:LA
Practice Address - Zip Code:71064
Practice Address - Country:US
Practice Address - Phone:318-326-4229
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-02
Last Update Date:2014-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA15876183500000X
OR12078183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist