Provider Demographics
NPI:1801414933
Name:DERAMED SPECIALTY LTC PHARMACY
Entity Type:Organization
Organization Name:DERAMED SPECIALTY LTC PHARMACY
Other - Org Name:DERAMED SPECIALTY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ADERONKE
Authorized Official - Middle Name:
Authorized Official - Last Name:EFUNOGBON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-592-3636
Mailing Address - Street 1:1001 MATLOCK RD STE 105
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-3443
Mailing Address - Country:US
Mailing Address - Phone:817-592-3636
Mailing Address - Fax:
Practice Address - Street 1:1001 MATLOCK RD STE 105
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-3443
Practice Address - Country:US
Practice Address - Phone:817-592-3636
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DERHANN CO. LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-07-06
Last Update Date:2022-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy