=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043668213
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NANCY TERRELL PHARMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/29/2016
-----------------------------------------------------
Last Update Date | 05/29/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1655 E 95TH ST
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60617-4707
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-731-9672
-----------------------------------------------------
Fax | 773-731-9676
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1655 E 95TH ST
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60617-4707
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-731-9672
-----------------------------------------------------
Fax | 773-731-9676
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 051.290313
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------