Provider Demographics
NPI:1457636102
Name:DERBY, DAVID ANTHONY
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:ANTHONY
Last Name:DERBY
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 1:6817 TAFT ST
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33024-5601
Mailing Address - Country:US
Mailing Address - Phone:954-989-8900
Mailing Address - Fax:954-989-6406
Practice Address - Street 1:6817 TAFT ST
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33024-5601
Practice Address - Country:US
Practice Address - Phone:954-989-8900
Practice Address - Fax:954-989-6406
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-13
Last Update Date:2011-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS30659183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL102025100Medicaid