Provider Demographics
NPI:1124676036
Name:MALONE, DEMETRIA MARY (PHARMD)
Entity type:Individual
Prefix:
First Name:DEMETRIA
Middle Name:MARY
Last Name:MALONE
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44 REPUBLIC DR APT 339
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06002-5460
Mailing Address - Country:US
Mailing Address - Phone:603-969-5564
Mailing Address - Fax:
Practice Address - Street 1:220 ALBANY TPKE
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:CT
Practice Address - Zip Code:06019-2565
Practice Address - Country:US
Practice Address - Phone:860-693-8329
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-04
Last Update Date:2019-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTPCT.0014531183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTPCT.0014531OtherPHARMACIST LICENSE