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General NPI Number Information
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NPI Number | 1093002164
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Entity Type | Individual
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Provider Name | CRISTINA N DIEDERICH PHARM. D.
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Gender | Female
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Dates
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Enumeration Date | 07/08/2011
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Last Update Date | 07/08/2011
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Provider Practice Location Address
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Address Line | 1911 JOHNSON AVE
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City | SAN LUIS OBISPO
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State | CA
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Zip | 93401-4131
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Country | US
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Telephone | 805-542-6339
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Fax |
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Provider Business Mailing Address
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Address Line | 834 BOUGAINVILLEA ST
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City | SAN LUIS OBISPO
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State | CA
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Zip | 93401-7609
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Country | US
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Telephone | 805-543-5071
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 49085
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License Number State | CA
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