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General NPI Number Information
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NPI Number | 1467854182
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Entity Type | Individual
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Provider Name | DIANE KOETZ RPH
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Gender | Female
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Dates
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Enumeration Date | 09/25/2014
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Last Update Date | 07/14/2022
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Provider Practice Location Address
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Address Line | 12480 ABERDEEN ST NE
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City | BLAINE
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State | MN
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Zip | 55449-4721
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Country | US
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Telephone | 763-862-6596
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Fax |
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Provider Business Mailing Address
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Address Line | 954 154TH AVE NE
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City | HAM LAKE
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State | MN
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Zip | 55304-5563
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Country | US
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Telephone |
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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 | RPH5666
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License Number State | ND
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Taxonomy #2
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 121785
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License Number State | MN
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