Healthcare Provider Details

I. General information

NPI: 1669721072
Provider Name (Legal Business Name): TERRY TYRRELL RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2012
Last Update Date: 08/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1455 BATTERSBY AVE
ENUMCLAW WA
98022-3634
US

IV. Provider business mailing address

PO BOX 218
ENUMCLAW WA
98022-0218
US

V. Phone/Fax

Practice location:
  • Phone: 360-802-8668
  • Fax: 360-802-8669
Mailing address:
  • Phone: 360-802-8668
  • Fax: 360-802-8669

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number00011049
License Number StateWA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: