Provider Demographics
NPI:1952735987
Name:PENROD, DERK (PHARMD)
Entity Type:Individual
Prefix:
First Name:DERK
Middle Name:
Last Name:PENROD
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:PO BOX 1177
Mailing Address - Street 2:
Mailing Address - City:SEASIDE
Mailing Address - State:OR
Mailing Address - Zip Code:97138
Mailing Address - Country:US
Mailing Address - Phone:801-842-3607
Mailing Address - Fax:
Practice Address - Street 1:401 S ROOSEVELT
Practice Address - Street 2:
Practice Address - City:SEASIDE
Practice Address - State:OR
Practice Address - Zip Code:97138
Practice Address - Country:US
Practice Address - Phone:503-738-4706
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-27
Last Update Date:2013-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR0013656183500000X
AK2079183500000X
MN120777183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist