Provider Demographics
NPI:1457659856
Name:OSBORNE, DEREK SPENCER
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:SPENCER
Last Name:OSBORNE
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 1:8121 REED CREEK HWY
Mailing Address - Street 2:
Mailing Address - City:HARTWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30643-2501
Mailing Address - Country:US
Mailing Address - Phone:706-376-4184
Mailing Address - Fax:706-245-1128
Practice Address - Street 1:8121 REED CREEK HWY
Practice Address - Street 2:
Practice Address - City:HARTWELL
Practice Address - State:GA
Practice Address - Zip Code:30643-2501
Practice Address - Country:US
Practice Address - Phone:706-376-4184
Practice Address - Fax:706-245-1128
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-09
Last Update Date:2011-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA016912183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist