Healthcare Provider Details

I. General information

NPI: 1164997169
Provider Name (Legal Business Name): DERHANN CO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2018
Last Update Date: 11/19/2025
Certification Date: 11/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 MATLOCK RD STE 105
MANSFIELD TX
76063-6564
US

IV. Provider business mailing address

1001 MATLOCK RD STE 105
MANSFIELD TX
76063-6564
US

V. Phone/Fax

Practice location:
  • Phone: 817-592-3636
  • Fax:
Mailing address:
  • Phone: 817-592-3636
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code332BP3500X
TaxonomyParenteral & Enteral Nutrition Supplies (DME)
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number StateNULL
# 6
Primary TaxonomyN
Taxonomy Code3336H0001X
TaxonomyHome Infusion Therapy Pharmacy
License Number
License Number StateNULL
# 7
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number StateNULL
# 8
Primary TaxonomyY
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number StateNULL
# 9
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number StateNULL
# 10
Primary TaxonomyN
Taxonomy Code335G00000X
TaxonomyMedical Foods Supplier
License Number
License Number StateNULL

VIII. Authorized Official

Name: ADERONKE EFUNOGBON
Title or Position: DIRECTOR
Credential:
Phone: 817-592-3636