Provider Demographics
NPI:1770925638
Name:GEORGE, DEREK WAYNE (PHARMD)
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:WAYNE
Last Name:GEORGE
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 1:4526 NW ROSSELLA CT
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:MO
Mailing Address - Zip Code:64150-7826
Mailing Address - Country:US
Mailing Address - Phone:425-305-8747
Mailing Address - Fax:
Practice Address - Street 1:4526 NW ROSSELLA CT
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:MO
Practice Address - Zip Code:64150-7826
Practice Address - Country:US
Practice Address - Phone:425-305-8747
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-20
Last Update Date:2021-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013022767183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist