Provider Demographics
NPI:1619276227
Name:DEICHERT, RENEE MARIE (RPH)
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:MARIE
Last Name:DEICHERT
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 1:27 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:COLCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06415-1001
Mailing Address - Country:US
Mailing Address - Phone:860-537-9034
Mailing Address - Fax:860-537-9023
Practice Address - Street 1:27 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:COLCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06415-1001
Practice Address - Country:US
Practice Address - Phone:860-537-9034
Practice Address - Fax:860-537-9023
Is Sole Proprietor?:No
Enumeration Date:2011-03-22
Last Update Date:2011-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT8790183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist