Healthcare Provider Details

I. General information

NPI: 1154924652
Provider Name (Legal Business Name): DR. DEREK KEGYEDA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/17/2020
Last Update Date: 01/08/2021
Certification Date: 01/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13800 HULL STREET RD
MIDLOTHIAN VA
23112-2002
US

IV. Provider business mailing address

13800 HULL STREET RD
MIDLOTHIAN VA
23112-2002
US

V. Phone/Fax

Practice location:
  • Phone: 804-739-2198
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number0202218461
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: