Provider Demographics
NPI:1609860469
Name:DERIENZO, PHILIP M (PHARM D)
Entity Type:Individual
Prefix:MR
First Name:PHILIP
Middle Name:M
Last Name:DERIENZO
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1013
Mailing Address - Street 2:335 WEST KING ST
Mailing Address - City:EAST BERLIN
Mailing Address - State:PA
Mailing Address - Zip Code:17316-1013
Mailing Address - Country:US
Mailing Address - Phone:717-259-0421
Mailing Address - Fax:717-259-7016
Practice Address - Street 1:335 W KING ST
Practice Address - Street 2:
Practice Address - City:EAST BERLIN
Practice Address - State:PA
Practice Address - Zip Code:17316-9730
Practice Address - Country:US
Practice Address - Phone:717-259-0421
Practice Address - Fax:717-259-7016
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP046184L183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist