Provider Demographics
NPI:1114242690
Name:DERIFIELD, JAMES G (RPH)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:G
Last Name:DERIFIELD
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 1:102 5TH AVENUE SO.
Mailing Address - Street 2:
Mailing Address - City:SO.ST.PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55075
Mailing Address - Country:US
Mailing Address - Phone:651-455-4140
Mailing Address - Fax:
Practice Address - Street 1:102 5TH AVE. NO
Practice Address - Street 2:
Practice Address - City:SO.ST.PAUL
Practice Address - State:MN
Practice Address - Zip Code:55075
Practice Address - Country:US
Practice Address - Phone:651-455-4140
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-29
Last Update Date:2010-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN111151183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist