Provider Demographics
NPI:1356302889
Name:DUTEAU, COREY JAMES (RPH)
Entity Type:Individual
Prefix:
First Name:COREY
Middle Name:JAMES
Last Name:DUTEAU
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 1:434 HURRICANE LN STE 200
Mailing Address - Street 2:
Mailing Address - City:WILLISTON
Mailing Address - State:VT
Mailing Address - Zip Code:05495-2073
Mailing Address - Country:US
Mailing Address - Phone:802-655-3544
Mailing Address - Fax:802-655-0123
Practice Address - Street 1:434 HURRICANE LN STE 200
Practice Address - Street 2:
Practice Address - City:WILLISTON
Practice Address - State:VT
Practice Address - Zip Code:05495-2073
Practice Address - Country:US
Practice Address - Phone:802-655-3544
Practice Address - Fax:802-655-0123
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-02
Last Update Date:2020-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY045591-1183500000X
VT033-0003368183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist