Provider Demographics
NPI:1790329209
Name:DERRICK, SHELBY JEANNE (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:SHELBY
Middle Name:JEANNE
Last Name:DERRICK
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44 E 52ND ST FL 2
Mailing Address - Street 2:
Mailing Address - City:BAYONNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07002-4119
Mailing Address - Country:US
Mailing Address - Phone:651-728-2555
Mailing Address - Fax:
Practice Address - Street 1:44 E 52ND ST FL 2
Practice Address - Street 2:
Practice Address - City:BAYONNE
Practice Address - State:NJ
Practice Address - Zip Code:07002-4119
Practice Address - Country:US
Practice Address - Phone:651-728-2555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-29
Last Update Date:2019-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI04024300183500000X
MN123985183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist