Provider Demographics
NPI:1659650596
Name:MIYASAKI, DEREK MICHAEL (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:DEREK
Middle Name:MICHAEL
Last Name:MIYASAKI
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 1:1799 MARLOW RD
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95401-4474
Mailing Address - Country:US
Mailing Address - Phone:707-528-3396
Mailing Address - Fax:
Practice Address - Street 1:1799 MARLOW RD
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95401-4474
Practice Address - Country:US
Practice Address - Phone:707-528-3396
Practice Address - Fax:707-528-0760
Is Sole Proprietor?:No
Enumeration Date:2011-08-10
Last Update Date:2016-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA64543183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist