Healthcare Provider Details

I. General information

NPI: 1649133414
Provider Name (Legal Business Name): DERRICK LEDVINA PHARM.D.
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2025
Last Update Date: 12/08/2025
Certification Date: 12/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1025 MARSH ST
MANKATO MN
56001-4752
US

IV. Provider business mailing address

1025 MARSH ST
MANKATO MN
56001-4752
US

V. Phone/Fax

Practice location:
  • Phone: 507-594-6388
  • Fax:
Mailing address:
  • Phone: 507-594-6388
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number122517
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: