Provider Demographics
NPI:1487961033
Name:KENDALL, DIANA MARIE (RPH)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:MARIE
Last Name:KENDALL
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MAPLE SHADE
Mailing Address - State:NJ
Mailing Address - Zip Code:08052-2411
Mailing Address - Country:US
Mailing Address - Phone:856-779-7304
Mailing Address - Fax:856-779-9022
Practice Address - Street 1:25 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MAPLE SHADE
Practice Address - State:NJ
Practice Address - Zip Code:08052-2411
Practice Address - Country:US
Practice Address - Phone:856-779-7304
Practice Address - Fax:856-779-9022
Is Sole Proprietor?:No
Enumeration Date:2010-09-02
Last Update Date:2010-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI01932700183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ4397606Medicaid