MEDICARE: CLENNY EDWARD TERRELL RPH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	20523	TX

General Provider Information

NPI Number	:	1053606228
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CLENNY EDWARD TERRELL RPH

Provider Business Mailing Address
First Line	:	PO BOX 1276
Second Line	:
City	:	WHITNEY
State	:	TX
Zip	:	76692-1276
Country	:	US
Telephone Number	:	254-675-4047
Fax Number	:

Provider Business Practice Location Address
First Line	:	1520 S. VALLEY MILLS DR.
Second Line	:
City	:	BEVELY HILLS
State	:	TX
Zip	:	76711
Country	:	US
Telephone Number	:	254-752-3986
Fax Number	:	254-752-4097

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/15/2011
Last Update Date	:	06/15/2011

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