Provider Demographics
NPI:1528458288
Name:SLOANE, DERRELL
Entity type:Individual
Prefix:
First Name:DERRELL
Middle Name:
Last Name:SLOANE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:908 WATCHUNG AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07060-2580
Mailing Address - Country:US
Mailing Address - Phone:908-546-8036
Mailing Address - Fax:
Practice Address - Street 1:1155 RT. 22W
Practice Address - Street 2:
Practice Address - City:WATCHUNG
Practice Address - State:NJ
Practice Address - Zip Code:07069
Practice Address - Country:US
Practice Address - Phone:908-756-8193
Practice Address - Fax:908-941-1701
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-02
Last Update Date:2015-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RW00433900183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician