Provider Demographics
NPI:1093893984
Name:ANDERSON, DERICK (PHARMD)
Entity Type:Individual
Prefix:
First Name:DERICK
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 STARK RD
Mailing Address - Street 2:
Mailing Address - City:DERRY
Mailing Address - State:NH
Mailing Address - Zip Code:03038-4611
Mailing Address - Country:US
Mailing Address - Phone:617-566-4080
Mailing Address - Fax:
Practice Address - Street 1:1180 BEACON ST
Practice Address - Street 2:
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02446-3885
Practice Address - Country:US
Practice Address - Phone:617-566-4080
Practice Address - Fax:617-566-2757
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2012-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA25168183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA25168OtherMASSACHUSETTS BOARD OF PHARMACY
NHR1998OtherNEW HAMPSHIRE BOARD OF PHARMACY