Provider Demographics
NPI:1255970646
Name:DEVENNY, ELISSA MARIE (PHARMD)
Entity type:Individual
Prefix:
First Name:ELISSA
Middle Name:MARIE
Last Name:DEVENNY
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:ELISSA
Other - Middle Name:MARIE
Other - Last Name:MULLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHARMD
Mailing Address - Street 1:142 S 52ND ST STE 201
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19139-3409
Mailing Address - Country:US
Mailing Address - Phone:215-471-4000
Mailing Address - Fax:215-471-4001
Practice Address - Street 1:142 S 52ND ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19139-3409
Practice Address - Country:US
Practice Address - Phone:215-471-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-02
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI04023100183500000X
PARP452580183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA104292130-0001Medicaid