MEDICARE: DEREK DISTASIO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	RH459005	PA

General Provider Information

NPI Number	:	1386464568
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEREK DISTASIO

Provider Business Mailing Address
First Line	:	2500 BOULEVARD OF THE GENERALS
Second Line	:
City	:	WEST NORRITON
State	:	PA
Zip	:	19403-3692
Country	:	US
Telephone Number	:	610-539-5093
Fax Number	:

Provider Business Practice Location Address
First Line	:	2500 BOULEVARD OF THE GENERALS
Second Line	:
City	:	WEST NORRITON
State	:	PA
Zip	:	19403-3692
Country	:	US
Telephone Number	:	610-539-5093
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/14/2024
Last Update Date	:	10/14/2024

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Directions to “ DEREK DISTASIO ” Practice Location

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