Provider Demographics
NPI:1164892238
Name:PATTERSON, DEREK
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:PATTERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5116 W OLIVE AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85302-4209
Mailing Address - Country:US
Mailing Address - Phone:623-937-4771
Mailing Address - Fax:
Practice Address - Street 1:5116 W OLIVE AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85302-4209
Practice Address - Country:US
Practice Address - Phone:623-937-4771
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-01
Last Update Date:2015-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS021609183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist