Provider Demographics
NPI:1811198427
Name:GRIMM, DEREK LEE (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:DEREK
Middle Name:LEE
Last Name:GRIMM
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 1:6005 COUNTRY CLUB DR
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25705-2038
Mailing Address - Country:US
Mailing Address - Phone:651-238-5732
Mailing Address - Fax:304-568-4425
Practice Address - Street 1:1540 SPRING VALLEY DR
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25704-9300
Practice Address - Country:US
Practice Address - Phone:304-429-6755
Practice Address - Fax:304-429-0270
Is Sole Proprietor?:No
Enumeration Date:2007-05-30
Last Update Date:2007-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVRP0006863183500000X
MN118655183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN118655OtherMINN BOARD OF PHARMACY
WVRP0006863OtherWV BOARD OF PHARMACY