Basic Information
Provider Information
NPI: 1033558994
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: WILLIAMS
FirstName: DIANE
MiddleName: RUTH
NamePrefix: MRS.
NameSuffix:  
Credential: RPH
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 15889 CEDARMILL DR
Address2:  
City: CHESTERFIELD
State: MO
PostalCode: 630178717
CountryCode: US
TelephoneNumber: 6365371911
FaxNumber:  
Practice Location
Address1: 2460 TAYLOR RD
Address2:  
City: WILDWOOD
State: MO
PostalCode: 630401222
CountryCode: US
TelephoneNumber: 6364587450
FaxNumber: 6365303002
Other Information
ProviderEnumerationDate: 06/24/2013
LastUpdateDate: 06/24/2013
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
183500000X030007MOY Pharmacy Service ProvidersPharmacist 

No ID Information.


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