Active NPI
Diane Koetz, RPH
- Pharmacist
- Blaine, MN
National Provider Identifier
1467854182
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Pharmacist
- License
- 121785
- Practice address
- 12480 Aberdeen St NE
Blaine, MN 55449-4721 - Phone
- (763) 862-6596
- NPI assigned
- Sep 25, 2014
- Last updated
- Jul 14, 2022
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 2
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Pharmacist | 183500000X | RPH5666 | ND | |
| Pharmacist | 183500000X | 121785 | MN | Primary |
Addresses
Primary practice location
12480 Aberdeen St NE
Blaine, MN 55449-4721
Mailing address
954 154TH Ave NE
Ham Lake, MN 55304-5563
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
- Credentials
- Registered Pharmacist
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 121785 | MN | MD | Pharmacist |
| RPH5666 | ND | MD | Pharmacist |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Walgreen Co | Past | Accepting new patients | |
| Walgreen Co | Past | Accepting new patients |
Organizations & group practices 2
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1411603200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1657756800000",
"number": "1467854182",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "954 154TH AVE NE",
"city": "HAM LAKE",
"state": "MN",
"postal_code": "553045563"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "12480 ABERDEEN ST NE",
"city": "BLAINE",
"state": "MN",
"postal_code": "554494721",
"telephone_number": "763-862-6596"
}
],
"practiceLocations": [],
"basic": {
"last_name": "KOETZ",
"first_name": "DIANE",
"credential": "RPH",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2014-09-25",
"last_updated": "2022-07-14",
"certification_date": "2022-07-14",
"status": "A"
},
"taxonomies": [
{
"code": "183500000X",
"taxonomy_group": "",
"desc": "Pharmacist",
"state": "ND",
"license": "RPH5666",
"primary": false
},
{
"code": "183500000X",
"taxonomy_group": "",
"desc": "Pharmacist",
"state": "MN",
"license": "121785",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Blaine, MN
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 14, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.