Provider Demographics
NPI:1629532213
Name:SMERNES, DEREK
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:SMERNES
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 1:2929 4TH ST
Mailing Address - Street 2:
Mailing Address - City:CERES
Mailing Address - State:CA
Mailing Address - Zip Code:95307-3290
Mailing Address - Country:US
Mailing Address - Phone:209-537-0718
Mailing Address - Fax:209-537-4252
Practice Address - Street 1:2929 4TH ST
Practice Address - Street 2:
Practice Address - City:CERES
Practice Address - State:CA
Practice Address - Zip Code:95307-3290
Practice Address - Country:US
Practice Address - Phone:209-537-0718
Practice Address - Fax:209-537-4252
Is Sole Proprietor?:No
Enumeration Date:2019-01-28
Last Update Date:2021-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA57222183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA57222OtherCALIFORNIA STATE BOARD OF PHARMACY