Provider Demographics
NPI:1124417738
Name:DERBY, DAVID (PHAMD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:
Last Name:DERBY
Suffix:
Gender:M
Credentials:PHAMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HOMINY
Mailing Address - State:OK
Mailing Address - Zip Code:74035-1032
Mailing Address - Country:US
Mailing Address - Phone:918-885-2715
Mailing Address - Fax:
Practice Address - Street 1:104 W MAIN ST
Practice Address - Street 2:
Practice Address - City:HOMINY
Practice Address - State:OK
Practice Address - Zip Code:74035-1032
Practice Address - Country:US
Practice Address - Phone:918-885-2715
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-20
Last Update Date:2015-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK15238183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist