Healthcare Provider Details

I. General information

NPI: 1124041496
Provider Name (Legal Business Name): DIANE S GRISAMORE PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2901 MONTOPOLIS DR
AUSTIN TX
78741-6411
US

IV. Provider business mailing address

7008 COVERED BRIDGE DR
AUSTIN TX
78736-3342
US

V. Phone/Fax

Practice location:
  • Phone: 512-389-6510
  • Fax:
Mailing address:
  • Phone: 512-301-4985
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number39330
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: