1306113352 NPI number — JACQUELINE DEROLF SUTTON PHARMD

Table of content: JACQUELINE DEROLF SUTTON PHARMD (NPI 1306113352)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306113352 NPI number — JACQUELINE DEROLF SUTTON PHARMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SUTTON
Provider First Name:
JACQUELINE
Provider Middle Name:
DEROLF
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PHARMD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1306113352
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/18/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
55 RAVENSWOOD WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SEWELL
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08080-3426
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
856-256-8147
Provider Business Mailing Address Fax Number:
856-968-8408

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1 COOPER PLZ
Provider Second Line Business Practice Location Address:
PHARMACY DEPARTMENT
Provider Business Practice Location Address City Name:
CAMDEN
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08103-1461
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
856-342-2339
Provider Business Practice Location Address Fax Number:
856-968-8408
Provider Enumeration Date:
11/18/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  28RI01838800 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2024 www.npivalidator.com