Provider Demographics
NPI:1629551411
Name:KOOMSON, DEREK (RPH)
Entity Type:Individual
Prefix:DR
First Name:DEREK
Middle Name:
Last Name:KOOMSON
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4805 EUGENE WAY
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21703-4801
Mailing Address - Country:US
Mailing Address - Phone:240-593-8723
Mailing Address - Fax:
Practice Address - Street 1:1631 DUAL HWY
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21740-6545
Practice Address - Country:US
Practice Address - Phone:240-313-9165
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-08
Last Update Date:2018-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD25963183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist