Healthcare Provider Details

I. General information

NPI: 1881730174
Provider Name (Legal Business Name): DERYCK K HILL RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 12/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

208 W. CASABLANCA AVE BLDG 1400 27 SOMDG
CANNON AFB NM
88103-5014
US

IV. Provider business mailing address

113 BURCH PL.
CLOVIS NM
88101
US

V. Phone/Fax

Practice location:
  • Phone: 575-784-4028
  • Fax:
Mailing address:
  • Phone: 575-218-3905
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number042824
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: