Provider Demographics
NPI:1912503889
Name:DUFRESNE, MARY
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:
Last Name:DUFRESNE
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 1:3004 MOUNT EPHRAIM AVE
Mailing Address - Street 2:
Mailing Address - City:HADDON TOWNSHIP
Mailing Address - State:NJ
Mailing Address - Zip Code:08104-3218
Mailing Address - Country:US
Mailing Address - Phone:856-854-9259
Mailing Address - Fax:856-869-4809
Practice Address - Street 1:3002 MT EPHRAIM AVE
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:NJ
Practice Address - Zip Code:08103
Practice Address - Country:US
Practice Address - Phone:856-854-9159
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-07
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI27328001835P2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P2201XPharmacy Service ProvidersPharmacistAmbulatory Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ28RI2732800OtherPHARMACIST LICENSE