Provider Demographics
NPI:1215211347
Name:BUTKOVICH, TERRI L
Entity Type:Individual
Prefix:
First Name:TERRI
Middle Name:L
Last Name:BUTKOVICH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4536 N COUNTY ROAD 13
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80524-9447
Mailing Address - Country:US
Mailing Address - Phone:970-221-1771
Mailing Address - Fax:
Practice Address - Street 1:3700 W 10TH ST
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80634-1819
Practice Address - Country:US
Practice Address - Phone:970-475-0192
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-07
Last Update Date:2013-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO11446183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist