Provider Demographics
NPI:1033269568
Name:DEROUEN, ELLIS RODNEY (RPH)
Entity Type:Individual
Prefix:MR
First Name:ELLIS
Middle Name:RODNEY
Last Name:DEROUEN
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 KELLEY BLVD
Mailing Address - Street 2:
Mailing Address - City:WOODVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75979-4714
Mailing Address - Country:US
Mailing Address - Phone:409-283-5487
Mailing Address - Fax:
Practice Address - Street 1:1010 W BLUFF ST
Practice Address - Street 2:
Practice Address - City:WOODVILLE
Practice Address - State:TX
Practice Address - Zip Code:75979-4736
Practice Address - Country:US
Practice Address - Phone:409-283-3073
Practice Address - Fax:409-283-2159
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX15009183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX143652Medicaid
TX4582664OtherNCPDP
TX4582664OtherNCPDP