Provider Demographics
NPI:1548723729
Name:HETTINGER, DEREK T
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:T
Last Name:HETTINGER
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 1:1432 E OLIVE ST
Mailing Address - Street 2:
Mailing Address - City:LAMAR
Mailing Address - State:CO
Mailing Address - Zip Code:81052-2958
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1432 E OLIVE ST
Practice Address - Street 2:
Practice Address - City:LAMAR
Practice Address - State:CO
Practice Address - Zip Code:81052-2958
Practice Address - Country:US
Practice Address - Phone:719-336-0541
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-13
Last Update Date:2019-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0022329183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist