Provider Demographics
NPI:1215259817
Name:DERHODES, KIM H (RPH)
Entity type:Individual
Prefix:MS
First Name:KIM
Middle Name:H
Last Name:DERHODES
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4525 CAMERON VALLEY PKWY
Mailing Address - Street 2:SUITE 1200
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28211-4369
Mailing Address - Country:US
Mailing Address - Phone:704-512-6040
Mailing Address - Fax:704-512-6041
Practice Address - Street 1:4525 CAMERON VALLEY PKWY
Practice Address - Street 2:SUITE 1200
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-4369
Practice Address - Country:US
Practice Address - Phone:704-512-6040
Practice Address - Fax:704-512-6041
Is Sole Proprietor?:No
Enumeration Date:2010-02-23
Last Update Date:2010-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC07798183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist