Provider Demographics
NPI:1215417647
Name:EGI, DERRICK (PHARM D)
Entity Type:Individual
Prefix:DR
First Name:DERRICK
Middle Name:
Last Name:EGI
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 W KETTLEMAN LN
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95240-6054
Mailing Address - Country:US
Mailing Address - Phone:209-368-5112
Mailing Address - Fax:209-368-4906
Practice Address - Street 1:1000 W KETTLEMAN LN
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95240-6054
Practice Address - Country:US
Practice Address - Phone:209-368-5112
Practice Address - Fax:209-368-4906
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-15
Last Update Date:2019-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA52587183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist