Provider Demographics
NPI:1235564329
Name:DERUSSY, DIANA JOY (PHARMD)
Entity Type:Individual
Prefix:MRS
First Name:DIANA
Middle Name:JOY
Last Name:DERUSSY
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:MISS
Other - First Name:DIANA
Other - Middle Name:JOY
Other - Last Name:GABRIEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHARMD
Mailing Address - Street 1:1600 EAST 23RD STREET
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37404
Mailing Address - Country:US
Mailing Address - Phone:423-629-4155
Mailing Address - Fax:423-622-4558
Practice Address - Street 1:1600 EAST 23RD ST
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37404
Practice Address - Country:US
Practice Address - Phone:423-629-4155
Practice Address - Fax:423-622-4558
Is Sole Proprietor?:No
Enumeration Date:2013-09-07
Last Update Date:2015-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN37211183500000X
GA022985183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN37211OtherTN PHARMACY LICENSE
TN147401OtherNABP