Provider Demographics
NPI:1649751652
Name:DERKOUCH, ADAM HICHAM (PHARMD)
Entity Type:Individual
Prefix:
First Name:ADAM
Middle Name:HICHAM
Last Name:DERKOUCH
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 1:6885 N WILLOW AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93710-5949
Mailing Address - Country:US
Mailing Address - Phone:559-322-0698
Mailing Address - Fax:
Practice Address - Street 1:5239 E HUNTINGTON AVE APT 202
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93727-4020
Practice Address - Country:US
Practice Address - Phone:917-547-0767
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-27
Last Update Date:2018-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA74579183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist