Provider Demographics
NPI:1679020580
Name:PUHALLA, DEREK (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:DEREK
Middle Name:
Last Name:PUHALLA
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 1:2370 FREEDOM BLVD
Mailing Address - Street 2:APT B2
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29505-6098
Mailing Address - Country:US
Mailing Address - Phone:724-650-2653
Mailing Address - Fax:
Practice Address - Street 1:2498 2ND LOOP RD
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29501-6162
Practice Address - Country:US
Practice Address - Phone:843-317-1233
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-08
Last Update Date:2016-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC36830183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist