Provider Demographics
NPI:1124669239
Name:DENNIS, DELOY LAMAR (PHARMACIST)
Entity type:Individual
Prefix:
First Name:DELOY
Middle Name:LAMAR
Last Name:DENNIS
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 E CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:SUTHERLIN
Mailing Address - State:OR
Mailing Address - Zip Code:97479-9556
Mailing Address - Country:US
Mailing Address - Phone:541-459-2712
Mailing Address - Fax:
Practice Address - Street 1:113 E CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:SUTHERLIN
Practice Address - State:OR
Practice Address - Zip Code:97479-9556
Practice Address - Country:US
Practice Address - Phone:541-915-7323
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-01
Last Update Date:2019-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR007066183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR007066Medicaid