MEDICARE: DEREK ETUBE PHARM.D

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	22934	MD

General Provider Information

NPI Number	:	1194121566
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEREK ETUBE PHARM.D

Provider Business Mailing Address
First Line	:	1030 W 41ST ST STE E
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21211-1662
Country	:	US
Telephone Number	:	410-235-0002
Fax Number	:

Provider Business Practice Location Address
First Line	:	1030 W 41ST ST STE E
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21211-1662
Country	:	US
Telephone Number	:	410-235-0002
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/13/2014
Last Update Date	:	12/21/2022

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