Provider Demographics
NPI:1336773167
Name:DERENNE, AMY M (PHARMD)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:M
Last Name:DERENNE
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 1:238 FRONT ST
Mailing Address - Street 2:
Mailing Address - City:CASHTON
Mailing Address - State:WI
Mailing Address - Zip Code:54619-2002
Mailing Address - Country:US
Mailing Address - Phone:608-654-5100
Mailing Address - Fax:605-654-5120
Practice Address - Street 1:238 FRONT ST
Practice Address - Street 2:
Practice Address - City:CASHTON
Practice Address - State:WI
Practice Address - Zip Code:54619-2002
Practice Address - Country:US
Practice Address - Phone:608-654-5100
Practice Address - Fax:608-654-5120
Is Sole Proprietor?:No
Enumeration Date:2020-03-02
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI19892-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist