Healthcare Provider Details

I. General information

NPI: 1063799559
Provider Name (Legal Business Name): THERESA HURST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/10/2011
Last Update Date: 11/10/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2301 E MARKET ST
LOGANSPORT IN
46947-2037
US

IV. Provider business mailing address

990 E 700 N
DELPHI IN
46923-8374
US

V. Phone/Fax

Practice location:
  • Phone: 574-735-3815
  • Fax: 574-739-0824
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number26018056A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: