Provider Demographics
NPI:1710411970
Name:DARBOUZE, DERRICK D
Entity type:Individual
Prefix:
First Name:DERRICK
Middle Name:D
Last Name:DARBOUZE
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 1:1901 CALLOWHILL ST
Mailing Address - Street 2:APT 219
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19130-4150
Mailing Address - Country:US
Mailing Address - Phone:201-458-4488
Mailing Address - Fax:
Practice Address - Street 1:4601 WESTFIELD AVE
Practice Address - Street 2:
Practice Address - City:PENNSAUKEN
Practice Address - State:NJ
Practice Address - Zip Code:08110-3029
Practice Address - Country:US
Practice Address - Phone:856-663-3405
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-14
Last Update Date:2017-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI03853300183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist