Provider Demographics
NPI:1427351691
Name:DEROSA, MICHAEL (PHARM D)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:DEROSA
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 RIVERFRONT DR
Mailing Address - Street 2:
Mailing Address - City:AMESBURY
Mailing Address - State:MA
Mailing Address - Zip Code:01913-4500
Mailing Address - Country:US
Mailing Address - Phone:781-760-8115
Mailing Address - Fax:
Practice Address - Street 1:114 CENTRAL ST
Practice Address - Street 2:
Practice Address - City:IPSWICH
Practice Address - State:MA
Practice Address - Zip Code:01938-1952
Practice Address - Country:US
Practice Address - Phone:978-356-9198
Practice Address - Fax:978-356-9108
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-09
Last Update Date:2010-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPH25737183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist