Provider Demographics
NPI:1205010386
Name:BLANK, TERRY A (RPH)
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:A
Last Name:BLANK
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1-15 N. CENTRAL AVE.
Mailing Address - Street 2:
Mailing Address - City:HARTSDALE
Mailing Address - State:NY
Mailing Address - Zip Code:10530-1912
Mailing Address - Country:US
Mailing Address - Phone:914-428-1612
Mailing Address - Fax:
Practice Address - Street 1:440 9TH AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10001-1620
Practice Address - Country:US
Practice Address - Phone:212-273-5700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-24
Last Update Date:2007-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY030649-1183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02379766Medicaid