Provider Demographics
NPI:1851573968
Name:CLOUSE, DENISE (PHARMACIST)
Entity Type:Individual
Prefix:
First Name:DENISE
Middle Name:
Last Name:CLOUSE
Suffix:
Gender:F
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6939 ERIE RD
Mailing Address - Street 2:
Mailing Address - City:DERBY
Mailing Address - State:NY
Mailing Address - Zip Code:14047-9406
Mailing Address - Country:US
Mailing Address - Phone:716-947-5066
Mailing Address - Fax:
Practice Address - Street 1:6939 ERIE RD
Practice Address - Street 2:
Practice Address - City:DERBY
Practice Address - State:NY
Practice Address - Zip Code:14047-9406
Practice Address - Country:US
Practice Address - Phone:716-947-5066
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-30
Last Update Date:2007-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY049821183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00861601Medicaid