Provider Demographics
NPI:1164705117
Name:DERECHO, LEONORA (RPH)
Entity Type:Individual
Prefix:MS
First Name:LEONORA
Middle Name:
Last Name:DERECHO
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50040 HARRISON ST
Mailing Address - Street 2:
Mailing Address - City:COACHELLA
Mailing Address - State:CA
Mailing Address - Zip Code:92236-1426
Mailing Address - Country:US
Mailing Address - Phone:760-391-5395
Mailing Address - Fax:760-398-6066
Practice Address - Street 1:80307 CAPRICE DR
Practice Address - Street 2:
Practice Address - City:INDIO
Practice Address - State:CA
Practice Address - Zip Code:92203-4833
Practice Address - Country:US
Practice Address - Phone:760-600-6906
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-26
Last Update Date:2011-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA63735183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist