Provider Demographics
NPI:1710519012
Name:QUAGRAINIE, DAMARIS
Entity Type:Individual
Prefix:
First Name:DAMARIS
Middle Name:
Last Name:QUAGRAINIE
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 1:3161 TREGO CT
Mailing Address - Street 2:
Mailing Address - City:WEST LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47906-8823
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:901 MACARTHUR BLVD
Practice Address - Street 2:
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-2901
Practice Address - Country:US
Practice Address - Phone:219-703-4185
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-05
Last Update Date:2020-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26028487A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist