MEDICARE: DR. TERRA H. LIDDIL RPH, PHARMD

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	PC00000096	NM
2	183500000X	Pharmacist	RP00005165	NM

General Provider Information

NPI Number	:	1427041870
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TERRA H. LIDDIL RPH, PHARMD

Provider Business Mailing Address
First Line	:	812 5TH ST
Second Line	:
City	:	LAS VEGAS
State	:	NM
Zip	:	87701-4330
Country	:	US
Telephone Number	:	505-425-3770
Fax Number	:

Provider Business Practice Location Address
First Line	:	812 5TH ST
Second Line	:
City	:	LAS VEGAS
State	:	NM
Zip	:	87701-4330
Country	:	US
Telephone Number	:	505-425-3770
Fax Number	:

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

Provider Enumeration Date	:	08/31/2005
Last Update Date	:	09/20/2013

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