Provider Demographics
NPI:1235218603
Name:MOORE, TERRY MACK I (DPH)
Entity Type:Individual
Prefix:MR
First Name:TERRY
Middle Name:MACK
Last Name:MOORE
Suffix:I
Gender:M
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1307 N SUNSET LN
Mailing Address - Street 2:
Mailing Address - City:GUYMON
Mailing Address - State:OK
Mailing Address - Zip Code:73942-3142
Mailing Address - Country:US
Mailing Address - Phone:580-338-7565
Mailing Address - Fax:580-338-7302
Practice Address - Street 1:115 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:GUYMON
Practice Address - State:OK
Practice Address - Zip Code:73942-3606
Practice Address - Country:US
Practice Address - Phone:580-338-7565
Practice Address - Fax:580-338-7302
Is Sole Proprietor?:No
Enumeration Date:2006-11-04
Last Update Date:2011-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK8742183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist