Provider Demographics
NPI:1821341785
Name:DERASMO, JACQUELINE (PHARM D)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:DERASMO
Suffix:
Gender:F
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 1:970 ROUTE 70
Mailing Address - Street 2:
Mailing Address - City:BRICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08724-3502
Mailing Address - Country:US
Mailing Address - Phone:732-206-8900
Mailing Address - Fax:
Practice Address - Street 1:970 ROUTE 70
Practice Address - Street 2:
Practice Address - City:BRICK
Practice Address - State:NJ
Practice Address - Zip Code:08724-3502
Practice Address - Country:US
Practice Address - Phone:732-206-8900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-17
Last Update Date:2012-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RIO3219700183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist