Provider Demographics
NPI:1376829374
Name:DERRICK, DENISE G
Entity Type:Individual
Prefix:
First Name:DENISE
Middle Name:G
Last Name:DERRICK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2320 RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:LEESVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29070-8013
Mailing Address - Country:US
Mailing Address - Phone:803-604-9115
Mailing Address - Fax:
Practice Address - Street 1:4079 AUGUSTA HIGHWAY
Practice Address - Street 2:SUITE A
Practice Address - City:GILBERT
Practice Address - State:SC
Practice Address - Zip Code:29054
Practice Address - Country:US
Practice Address - Phone:803-892-6789
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-24
Last Update Date:2020-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC9699183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist