Provider Demographics
NPI:1467859629
Name:AUSTIN, DERRICK
Entity Type:Individual
Prefix:
First Name:DERRICK
Middle Name:
Last Name:AUSTIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:DERRICK
Other - Middle Name:
Other - Last Name:AUSTIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHARMD
Mailing Address - Street 1:64 GILES ST
Mailing Address - Street 2:
Mailing Address - City:HEFLIN
Mailing Address - State:AL
Mailing Address - Zip Code:36264-1738
Mailing Address - Country:US
Mailing Address - Phone:256-393-4063
Mailing Address - Fax:256-463-2026
Practice Address - Street 1:64 GILES ST
Practice Address - Street 2:
Practice Address - City:HEFLIN
Practice Address - State:AL
Practice Address - Zip Code:36264-1738
Practice Address - Country:US
Practice Address - Phone:256-393-4063
Practice Address - Fax:256-463-2026
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-03
Last Update Date:2015-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL10984183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL10984OtherALBAMA LICENSE NUMBER