Healthcare Provider Details

I. General information

NPI: 1124417738
Provider Name (Legal Business Name): DAVID DERBY PHAMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/20/2015
Last Update Date: 01/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 W MAIN ST
HOMINY OK
74035-1032
US

IV. Provider business mailing address

104 W MAIN ST
HOMINY OK
74035-1032
US

V. Phone/Fax

Practice location:
  • Phone: 918-885-2715
  • Fax:
Mailing address:
  • Phone: 918-885-2715
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number15238
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: