Provider Demographics
NPI:1598210445
Name:DEROSSI, JARED (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:JARED
Middle Name:
Last Name:DEROSSI
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117A VILLAGE RD NE
Mailing Address - Street 2:
Mailing Address - City:LELAND
Mailing Address - State:NC
Mailing Address - Zip Code:28451-7413
Mailing Address - Country:US
Mailing Address - Phone:910-371-6363
Mailing Address - Fax:
Practice Address - Street 1:117A VILLAGE RD NE
Practice Address - Street 2:
Practice Address - City:LELAND
Practice Address - State:NC
Practice Address - Zip Code:28451-7413
Practice Address - Country:US
Practice Address - Phone:910-371-6363
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-22
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC26482183500000X
NYI062106-1183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist