Provider Demographics
NPI:1245788157
Name:GYLLENHAMMER, DEREK
Entity Type:Individual
Prefix:DR
First Name:DEREK
Middle Name:
Last Name:GYLLENHAMMER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:163 MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:SUFFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06078-2005
Mailing Address - Country:US
Mailing Address - Phone:860-668-5115
Mailing Address - Fax:860-668-0856
Practice Address - Street 1:163 MOUNTAIN RD
Practice Address - Street 2:
Practice Address - City:SUFFIELD
Practice Address - State:CT
Practice Address - Zip Code:06078-2005
Practice Address - Country:US
Practice Address - Phone:860-668-5115
Practice Address - Fax:860-668-0856
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-20
Last Update Date:2016-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT13809183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist