Basic Information
Provider Information | |||||||||
NPI: | 1437188810 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DESRUISSEAU | ||||||||
FirstName: | JENNIFER | ||||||||
MiddleName: | ELLEN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PHARM.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 200 2ND AVE S # 489 | ||||||||
Address2: |   | ||||||||
City: | SAINT PETERSBURG | ||||||||
State: | FL | ||||||||
PostalCode: | 337014313 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9073601566 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 17025 SNOWMOBILE LN | ||||||||
Address2: |   | ||||||||
City: | EAGLE RIVER | ||||||||
State: | AK | ||||||||
PostalCode: | 995777044 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9076967466 | ||||||||
FaxNumber: | 9077260332 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/30/2006 | ||||||||
LastUpdateDate: | 03/19/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/19/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1835P1200X | PS34270 | FL | Y |   | Pharmacy Service Providers | Pharmacist | Pharmacotherapy |
No ID Information.