Healthcare Provider Details

I. General information

NPI: 1366723868
Provider Name (Legal Business Name): DICK J DERKS PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/29/2011
Last Update Date: 08/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7251 LAKE ST
RIVER FOREST IL
60305-2238
US

IV. Provider business mailing address

1020 S WABASH AVE UNIT 4C
CHICAGO IL
60605-2256
US

V. Phone/Fax

Practice location:
  • Phone: 708-366-9960
  • Fax: 708-366-1585
Mailing address:
  • Phone: 708-870-3674
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051289507
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: