Provider Demographics
NPI:1376865238
Name:DERRENBACHER, TONI M (RPH)
Entity Type:Individual
Prefix:MS
First Name:TONI
Middle Name:M
Last Name:DERRENBACHER
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 VALMONT CT
Mailing Address - Street 2:
Mailing Address - City:LAKE GROVE
Mailing Address - State:NY
Mailing Address - Zip Code:11755-1640
Mailing Address - Country:US
Mailing Address - Phone:631-619-4125
Mailing Address - Fax:
Practice Address - Street 1:4331 NESCONSET HWY
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-2250
Practice Address - Country:US
Practice Address - Phone:631-642-3019
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-19
Last Update Date:2010-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY049227-1183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist