Healthcare Provider Details

I. General information

NPI: 1972108934
Provider Name (Legal Business Name): MR. GREG DERDERIAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2020
Last Update Date: 11/30/2020
Certification Date: 11/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

160 S MAIN ST
DOYLESTOWN PA
18901-4875
US

IV. Provider business mailing address

160 S MAIN ST
DOYLESTOWN PA
18901-4875
US

V. Phone/Fax

Practice location:
  • Phone: 215-230-1960
  • Fax:
Mailing address:
  • Phone: 215-230-1690
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P2201X
TaxonomyAmbulatory Care Pharmacist
License NumberRP438742
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: