Provider Demographics
NPI:1073296737
Name:DERIVAL, JACQUES GREGOIRE (RPH)
Entity Type:Individual
Prefix:
First Name:JACQUES
Middle Name:GREGOIRE
Last Name:DERIVAL
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 1:12885 SW 1ST LN APT 408
Mailing Address - Street 2:
Mailing Address - City:NEWBERRY
Mailing Address - State:FL
Mailing Address - Zip Code:32669-3587
Mailing Address - Country:US
Mailing Address - Phone:786-338-5076
Mailing Address - Fax:
Practice Address - Street 1:2815 NW 13TH ST STE 204
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32609-2879
Practice Address - Country:US
Practice Address - Phone:352-204-5643
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-09
Last Update Date:2024-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS63339183500000X
KS1-119122183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist