Healthcare Provider Details

I. General information

NPI: 1619089984
Provider Name (Legal Business Name): TERRY L ROLLER D.PH.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 N MAIN AVE
ERWIN TN
37650-1255
US

IV. Provider business mailing address

109 N MAIN AVE
ERWIN TN
37650-1255
US

V. Phone/Fax

Practice location:
  • Phone: 423-743-7105
  • Fax: 423-743-7167
Mailing address:
  • Phone: 423-743-7105
  • Fax: 423-743-7167

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number1406
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: