NPIMap

Individual provider Active NPI

Dereck Realejo

  • Pharmacist
  • New London, CT
National Provider Identifier
1003270125
Registry record updated Apr 6, 2016
On this page

Key facts

NPPES NPI Registry
Primary specialty
PharmacistTaxonomy code 183500000X
License
13436 Issued in CT
Practice address
817 Bank St
New London, CT 06320
Phone
(860) 443-5359
Fax
(860) 440-3336
NPI assigned
Apr 6, 2016
Sex
Male
Sole proprietor
Yes

NPPES NPI Registry

Updated by the provider on Apr 6, 2016

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Pharmacist 183500000X 13436 CT Primary

Addresses

Primary practice location

817 Bank St
New London, CT 06320

Mailing address

817 Bank St
New London, CT 06320
Phone (860) 443-5359

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Not listed in the public Medicare enrollment file

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Not enrolled

State licenses

LicenseStateTypeSpecialty
13436CTMDPhysical Therapist

Practice roles

OrganizationSpecialtyStatusNew patients
Connecticut CVS Pharmacy, L.L.C. Past Accepting new patients
Connecticut CVS Pharmacy LLC Past Accepting new patients

Organizations & group practices 2

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1459900800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1459900800000",
    "number": "1003270125",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "817 BANK ST",
            "city": "NEW LONDON",
            "state": "CT",
            "postal_code": "06320",
            "telephone_number": "860-443-5359",
            "fax_number": "860-440-3336"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "817 BANK ST",
            "city": "NEW LONDON",
            "state": "CT",
            "postal_code": "06320",
            "telephone_number": "860-443-5359",
            "fax_number": "860-440-3336"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "REALEJO",
        "first_name": "DERECK",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2016-04-06",
        "last_updated": "2016-04-06",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "183500000X",
            "taxonomy_group": "",
            "desc": "Pharmacist",
            "state": "CT",
            "license": "13436",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in New London, CT

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 6, 2016; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.