MEDICARE: MR. PHILIP M DERIENZO PHARM D

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	RP046184L	PA

General Provider Information

NPI Number	:	1609860469
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. PHILIP M DERIENZO PHARM D

Provider Business Mailing Address
First Line	:	PO BOX 1013
Second Line	:	335 WEST KING ST
City	:	EAST BERLIN
State	:	PA
Zip	:	17316-1013
Country	:	US
Telephone Number	:	717-259-0421
Fax Number	:	717-259-7016

Provider Business Practice Location Address
First Line	:	335 W KING ST
Second Line	:
City	:	EAST BERLIN
State	:	PA
Zip	:	17316-9730
Country	:	US
Telephone Number	:	717-259-0421
Fax Number	:	717-259-7016

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/08/2005
Last Update Date	:	07/08/2007

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