Provider Demographics
NPI:1104544071
Name:BACON, DERRICK (PHARMACY TECH)
Entity type:Individual
Prefix:
First Name:DERRICK
Middle Name:
Last Name:BACON
Suffix:
Gender:M
Credentials:PHARMACY TECH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:360 MARTIN LUTHER KING JR BLVD N
Mailing Address - Street 2:
Mailing Address - City:PONTIAC
Mailing Address - State:MI
Mailing Address - Zip Code:48342-1712
Mailing Address - Country:US
Mailing Address - Phone:248-332-0602
Mailing Address - Fax:
Practice Address - Street 1:360 MARTIN LUTHER KING JR BLVD N
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48342-1712
Practice Address - Country:US
Practice Address - Phone:248-332-0602
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-17
Last Update Date:2022-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5303041916183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician