Provider Demographics
NPI:1538551437
Name:IM, DERRICK
Entity type:Individual
Prefix:
First Name:DERRICK
Middle Name:
Last Name:IM
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 1:5837 S CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90001-1127
Mailing Address - Country:US
Mailing Address - Phone:323-233-2493
Mailing Address - Fax:
Practice Address - Street 1:5837 S CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90001
Practice Address - Country:US
Practice Address - Phone:323-233-2493
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-02
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA75199183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA200991908WAMedicaid