Provider Demographics
NPI:1619578507
Name:BARA, DIANE (RPH)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:BARA
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:DIANE
Other - Middle Name:
Other - Last Name:BARA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RPH
Mailing Address - Street 1:11 RIM RD
Mailing Address - Street 2:
Mailing Address - City:KILGORE
Mailing Address - State:TX
Mailing Address - Zip Code:75662-2228
Mailing Address - Country:US
Mailing Address - Phone:903-985-2340
Mailing Address - Fax:
Practice Address - Street 1:1201 STONE ST
Practice Address - Street 2:
Practice Address - City:KILGORE
Practice Address - State:TX
Practice Address - Zip Code:75662-5433
Practice Address - Country:US
Practice Address - Phone:903-983-1056
Practice Address - Fax:903-983-1242
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-05
Last Update Date:2020-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX26856183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist