Provider Demographics
NPI:1902808074
Name:MARKS, DIANE MARIE (RPH)
Entity Type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:MARIE
Last Name:MARKS
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 1:3664 COUNTY LINE RD
Mailing Address - Street 2:
Mailing Address - City:COLGATE
Mailing Address - State:WI
Mailing Address - Zip Code:53017-9302
Mailing Address - Country:US
Mailing Address - Phone:262-224-4618
Mailing Address - Fax:
Practice Address - Street 1:W180N8085 TOWN HALL RD
Practice Address - Street 2:
Practice Address - City:MENOMONEE FALLS
Practice Address - State:WI
Practice Address - Zip Code:53051-3518
Practice Address - Country:US
Practice Address - Phone:262-257-3070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2007-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI12011-040183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist