Provider Demographics
NPI:1518584739
Name:STREETER, DEREK
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:STREETER
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 1:6745 E SOUTHPORT RD
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46237-9728
Mailing Address - Country:US
Mailing Address - Phone:317-887-0691
Mailing Address - Fax:
Practice Address - Street 1:6745 E SOUTHPORT RD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46237-9728
Practice Address - Country:US
Practice Address - Phone:317-887-0691
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-03
Last Update Date:2020-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26028797A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist