Provider Demographics
NPI:1518663483
Name:ATABONG, DERICK T (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:DERICK
Middle Name:T
Last Name:ATABONG
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 JAMES BOWIE DR
Mailing Address - Street 2:
Mailing Address - City:NEW BOSTON
Mailing Address - State:TX
Mailing Address - Zip Code:75570-2334
Mailing Address - Country:US
Mailing Address - Phone:903-628-5557
Mailing Address - Fax:
Practice Address - Street 1:4000 NEW BOSTON RD
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75501-2819
Practice Address - Country:US
Practice Address - Phone:903-831-3023
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-02
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX64658183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist