Provider Demographics
NPI:1003584855
Name:PUCKETT, DEANNA
Entity Type:Individual
Prefix:
First Name:DEANNA
Middle Name:
Last Name:PUCKETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DEANNA
Other - Middle Name:
Other - Last Name:RICE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2 OLD CAMP RD
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21702-3740
Mailing Address - Country:US
Mailing Address - Phone:301-473-4201
Mailing Address - Fax:301-473-8995
Practice Address - Street 1:2 OLD CAMP RD
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21702-3740
Practice Address - Country:US
Practice Address - Phone:301-473-4201
Practice Address - Fax:301-473-8995
Is Sole Proprietor?:No
Enumeration Date:2021-09-04
Last Update Date:2021-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDT17055183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist