Provider Demographics
NPI:1972108934
Name:DERDERIAN, GREG
Entity type:Individual
Prefix:MR
First Name:GREG
Middle Name:
Last Name:DERDERIAN
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 1:160 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DOYLESTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18901-4875
Mailing Address - Country:US
Mailing Address - Phone:215-230-1690
Mailing Address - Fax:
Practice Address - Street 1:160 S MAIN ST
Practice Address - Street 2:
Practice Address - City:DOYLESTOWN
Practice Address - State:PA
Practice Address - Zip Code:18901-4875
Practice Address - Country:US
Practice Address - Phone:215-230-1960
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-30
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP4387421835P2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P2201XPharmacy Service ProvidersPharmacistAmbulatory Care