Healthcare Provider Details

I. General information

NPI: 1558596718
Provider Name (Legal Business Name): TERRY EUGENE TIBBETTS RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2009
Last Update Date: 05/18/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5974 PENTZ RD
PARADISE CA
95969-5509
US

IV. Provider business mailing address

5974 PENTZ RD
PARADISE CA
95969-5509
US

V. Phone/Fax

Practice location:
  • Phone: 530-876-7177
  • Fax: 530-876-2137
Mailing address:
  • Phone: 530-876-7177
  • Fax: 530-876-2137

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number29036
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: