Provider Demographics
NPI:1316230824
Name:KIMREY, DERRICK BRIAN
Entity Type:Individual
Prefix:MR
First Name:DERRICK
Middle Name:BRIAN
Last Name:KIMREY
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 1:790 TIMBER DR
Mailing Address - Street 2:
Mailing Address - City:GARNER
Mailing Address - State:NC
Mailing Address - Zip Code:27529-4852
Mailing Address - Country:US
Mailing Address - Phone:919-661-9992
Mailing Address - Fax:
Practice Address - Street 1:790 TIMBER DR
Practice Address - Street 2:
Practice Address - City:GARNER
Practice Address - State:NC
Practice Address - Zip Code:27529-4852
Practice Address - Country:US
Practice Address - Phone:919-661-9992
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-17
Last Update Date:2011-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC12619183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist