Provider Demographics
NPI:1295234714
Name:DERRY, NICOLE MICHELLE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:MICHELLE
Last Name:DERRY
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 1:293 OLD STAGE RD
Mailing Address - Street 2:
Mailing Address - City:ALTAMONT
Mailing Address - State:NY
Mailing Address - Zip Code:12009-3308
Mailing Address - Country:US
Mailing Address - Phone:518-256-9301
Mailing Address - Fax:
Practice Address - Street 1:293 OLD STAGE RD
Practice Address - Street 2:
Practice Address - City:ALTAMONT
Practice Address - State:NY
Practice Address - Zip Code:12009-3308
Practice Address - Country:US
Practice Address - Phone:518-256-9301
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-10
Last Update Date:2018-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY062745183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist