MEDICARE: TERRY MICHAEL MADDOX PHARM D

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist		IL

General Provider Information

NPI Number	:	1346295367
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TERRY MICHAEL MADDOX PHARM D

Provider Business Mailing Address
First Line	:	1833 KINGSHIGHWAY
Second Line	:	SUITE 200
City	:	WASHINGTON PARK
State	:	IL
Zip	:	62204-2135
Country	:	US
Telephone Number	:	618-874-3000
Fax Number	:	618-874-3019

Provider Business Practice Location Address
First Line	:	1833 KINGSHIGHWAY
Second Line	:	SUITE 200
City	:	WASHINGTON PARK
State	:	IL
Zip	:	62204-2135
Country	:	US
Telephone Number	:	618-874-3000
Fax Number	:	618-874-3019

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/24/2006
Last Update Date	:	07/08/2007

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