Provider Demographics
NPI:1164977526
Name:TETREAU, DAVID
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:TETREAU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4520 W 7TH ST
Mailing Address - Street 2:
Mailing Address - City:WAKE VILLAGE
Mailing Address - State:TX
Mailing Address - Zip Code:75501-6354
Mailing Address - Country:US
Mailing Address - Phone:903-838-7539
Mailing Address - Fax:
Practice Address - Street 1:4520 W 7TH ST
Practice Address - Street 2:
Practice Address - City:WAKE VILLAGE
Practice Address - State:TX
Practice Address - Zip Code:75501-6354
Practice Address - Country:US
Practice Address - Phone:903-838-7539
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-16
Last Update Date:2016-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX48450183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist