Provider Demographics
NPI:1407451016
Name:DEROUEN, MARISSA
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:DEROUEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 W CENTER ST
Mailing Address - Street 2:
Mailing Address - City:WEST BRIDGEWATER
Mailing Address - State:MA
Mailing Address - Zip Code:02379-1741
Mailing Address - Country:US
Mailing Address - Phone:508-588-8050
Mailing Address - Fax:
Practice Address - Street 1:2 W CENTER ST
Practice Address - Street 2:
Practice Address - City:WEST BRIDGEWATER
Practice Address - State:MA
Practice Address - Zip Code:02379-1741
Practice Address - Country:US
Practice Address - Phone:508-588-8050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-01
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA239755183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist