Healthcare Provider Details

I. General information

NPI: 1972773844
Provider Name (Legal Business Name): TERRY LEE TELLER PHARM.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2008
Last Update Date: 03/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

NAVAJO ROUTE 64 AND 12 TSAILE HEALTH CENTER
TSAILE AZ
86556-0467
US

IV. Provider business mailing address

PO BOX 467
TSAILE AZ
86556-0467
US

V. Phone/Fax

Practice location:
  • Phone: 928-724-3644
  • Fax: 928-724-3605
Mailing address:
  • Phone: 928-724-3644
  • Fax: 928-724-3605

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP00007081
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: