Provider Demographics
NPI:1073802484
Name:DERUE, GINA MARIE (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:GINA
Middle Name:MARIE
Last Name:DERUE
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:DR
Other - First Name:GINA
Other - Middle Name:MARIE
Other - Last Name:FERRIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHARMD
Mailing Address - Street 1:5 STOUGHTON LN
Mailing Address - Street 2:
Mailing Address - City:ORCHARD PARK
Mailing Address - State:NY
Mailing Address - Zip Code:14127-2083
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1083 DELAWARE AVE
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14209-1635
Practice Address - Country:US
Practice Address - Phone:716-862-2186
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-06
Last Update Date:2012-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY054735183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist