Provider Demographics
NPI:1346922366
Name:DEFORGE, WARREN MATTHEW
Entity Type:Individual
Prefix:
First Name:WARREN
Middle Name:MATTHEW
Last Name:DEFORGE
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 1:41 PARK AVENUE EXT
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02474-2656
Mailing Address - Country:US
Mailing Address - Phone:713-201-2637
Mailing Address - Fax:
Practice Address - Street 1:825 MORTON ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02126-1850
Practice Address - Country:US
Practice Address - Phone:617-298-3114
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-01
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPH25665183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist