Provider Demographics
NPI:1841404399
Name:DERITIS, DOUGLAS JOSEPH (PHARMD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:JOSEPH
Last Name:DERITIS
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 1:159 SMITH CIR
Mailing Address - Street 2:
Mailing Address - City:POINT PLEASANT BORO
Mailing Address - State:NJ
Mailing Address - Zip Code:08742-5414
Mailing Address - Country:US
Mailing Address - Phone:732-892-8881
Mailing Address - Fax:
Practice Address - Street 1:200 TRENTON RD
Practice Address - Street 2:
Practice Address - City:BROWNS MILLS
Practice Address - State:NJ
Practice Address - Zip Code:08015-1705
Practice Address - Country:US
Practice Address - Phone:609-893-6611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI02086000183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist