Healthcare Provider Details

I. General information

NPI: 1356302889
Provider Name (Legal Business Name): COREY JAMES DUTEAU R.PH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/02/2006
Last Update Date: 01/14/2020
Certification Date: 01/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

434 HURRICANE LN STE 200
WILLISTON VT
05495-2073
US

IV. Provider business mailing address

434 HURRICANE LN STE 200
WILLISTON VT
05495-2073
US

V. Phone/Fax

Practice location:
  • Phone: 802-655-3544
  • Fax: 802-655-0123
Mailing address:
  • Phone: 802-655-3544
  • Fax: 802-655-0123

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number045591-1
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number033-0003368
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: