Provider Demographics
NPI:1578164612
Name:DEAUSEN, TERESA
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:DEAUSEN
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 1:1155 ANNAPOLIS RD
Mailing Address - Street 2:
Mailing Address - City:ODENTON
Mailing Address - State:MD
Mailing Address - Zip Code:21113-1633
Mailing Address - Country:US
Mailing Address - Phone:410-305-1291
Mailing Address - Fax:
Practice Address - Street 1:1155 ANNAPOLIS RD
Practice Address - Street 2:
Practice Address - City:ODENTON
Practice Address - State:MD
Practice Address - Zip Code:21113-1633
Practice Address - Country:US
Practice Address - Phone:410-305-1291
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-05
Last Update Date:2020-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD17756183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist