Healthcare Provider Details

I. General information

NPI: 1912282716
Provider Name (Legal Business Name): MRS. TERRI F MCKETTRICK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2011
Last Update Date: 10/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2744 WASHINGTON RD
AUGUSTA GA
30909-2218
US

IV. Provider business mailing address

2215 MORNINGSIDE DR
AUGUSTA GA
30904-3441
US

V. Phone/Fax

Practice location:
  • Phone: 706-733-4277
  • Fax:
Mailing address:
  • Phone: 706-736-9672
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number13389
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: