Provider Demographics
NPI:1083727234
Name:DEERFIELD PHARMACY
Entity Type:Organization
Organization Name:DEERFIELD PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RPH/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:FYDENKEVEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:413-665-8143
Mailing Address - Street 1:45 MAIN ST.
Mailing Address - Street 2:
Mailing Address - City:S. DEERFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01373-1012
Mailing Address - Country:US
Mailing Address - Phone:413-665-8143
Mailing Address - Fax:
Practice Address - Street 1:45 MAIN ST.
Practice Address - Street 2:
Practice Address - City:S. DEERFIELD
Practice Address - State:MA
Practice Address - Zip Code:01373-1012
Practice Address - Country:US
Practice Address - Phone:413-665-8143
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-15
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MABD3077307183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0491760001Medicare NSC