Provider Demographics
NPI:1700478575
Name:ETHRIDGE, DEREK MADISON (RPH)
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:MADISON
Last Name:ETHRIDGE
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1757 SUNFLOWER BLF
Mailing Address - Street 2:
Mailing Address - City:NEW BRAUNFELS
Mailing Address - State:TX
Mailing Address - Zip Code:78130-1958
Mailing Address - Country:US
Mailing Address - Phone:210-364-4441
Mailing Address - Fax:
Practice Address - Street 1:19450 MCDONALD ST STE 102
Practice Address - Street 2:
Practice Address - City:LYTLE
Practice Address - State:TX
Practice Address - Zip Code:78052-3649
Practice Address - Country:US
Practice Address - Phone:830-988-0100
Practice Address - Fax:830-988-0111
Is Sole Proprietor?:No
Enumeration Date:2021-02-03
Last Update Date:2021-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX30227183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist