Provider Demographics
NPI:1922697085
Name:TEA, DEREK
Entity Type:Individual
Prefix:DR
First Name:DEREK
Middle Name:
Last Name:TEA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5151 N 16TH ST APT 4038
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-3817
Mailing Address - Country:US
Mailing Address - Phone:562-685-1927
Mailing Address - Fax:
Practice Address - Street 1:5115 W BASELINE RD
Practice Address - Street 2:
Practice Address - City:LAVEEN
Practice Address - State:AZ
Practice Address - Zip Code:85339-3000
Practice Address - Country:US
Practice Address - Phone:602-283-1603
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-13
Last Update Date:2021-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS024816183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist