1588017727 NPI number — MR. CHARLES GREGOR FLORES DERUPE PHARMD

Table of content: MR. CHARLES GREGOR FLORES DERUPE PHARMD (NPI 1588017727)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588017727 NPI number — MR. CHARLES GREGOR FLORES DERUPE PHARMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DERUPE
Provider First Name:
CHARLES GREGOR
Provider Middle Name:
FLORES
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PHARMD
Provider Gender Code:
M

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:
1588017727
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/15/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1599
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BANGOR
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04402-1599
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1100 NINTH AVE
Provider Second Line Business Practice Location Address:
X8-END
Provider Business Practice Location Address City Name:
SEATTLE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98102
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
206-223-6627
Provider Business Practice Location Address Fax Number:
206-223-2313
Provider Enumeration Date:
07/22/2016

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:  PR45384 , registered in the state of ME ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1835P0018X , with the licence number: PH60799926 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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