Provider Demographics
NPI:1104008440
Name:DEANE, GRATIA C (RPH,MS)
Entity Type:Individual
Prefix:
First Name:GRATIA
Middle Name:C
Last Name:DEANE
Suffix:
Gender:F
Credentials:RPH,MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:279 TROY RD
Mailing Address - Street 2:
Mailing Address - City:RENSSELAER
Mailing Address - State:NY
Mailing Address - Zip Code:12144-9499
Mailing Address - Country:US
Mailing Address - Phone:518-283-3021
Mailing Address - Fax:518-283-3031
Practice Address - Street 1:279 TROY RD
Practice Address - Street 2:
Practice Address - City:RENSSELAER
Practice Address - State:NY
Practice Address - Zip Code:12144-9499
Practice Address - Country:US
Practice Address - Phone:518-283-3021
Practice Address - Fax:518-283-3031
Is Sole Proprietor?:No
Enumeration Date:2007-11-28
Last Update Date:2007-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY35046183500000X
MA17539183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01394852Medicaid
NY4355050970Medicare UPIN