Provider Demographics
NPI:1336424118
Name:DERDERIAN, JAMES (PHARMD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:
Last Name:DERDERIAN
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 1:100 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:PAWTUCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02860
Mailing Address - Country:US
Mailing Address - Phone:401-724-6724
Mailing Address - Fax:
Practice Address - Street 1:100 BROAD ST
Practice Address - Street 2:
Practice Address - City:PAWTUCKET
Practice Address - State:RI
Practice Address - Zip Code:02860
Practice Address - Country:US
Practice Address - Phone:401-724-6724
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-12
Last Update Date:2011-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI04856183500000X
MA232948183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist