Provider Demographics
NPI:1194790600
Name:DERENBURGER, JOHN A
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:A
Last Name:DERENBURGER
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 1:1990 PARKWOOD RD
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25314-2242
Mailing Address - Country:US
Mailing Address - Phone:304-345-6124
Mailing Address - Fax:304-388-8838
Practice Address - Street 1:3200 MACCORKLE AVE SE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25304-1227
Practice Address - Country:US
Practice Address - Phone:304-388-4210
Practice Address - Fax:304-388-8838
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV0005220183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist