Provider Demographics
NPI:1235410283
Name:MUCKLEY, TERESA L (RPH)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:L
Last Name:MUCKLEY
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:940 DRIFTWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:IN
Mailing Address - Zip Code:47203-1083
Mailing Address - Country:US
Mailing Address - Phone:812-378-9934
Mailing Address - Fax:812-346-7058
Practice Address - Street 1:9 N STATE ST
Practice Address - Street 2:
Practice Address - City:NORTH VERNON
Practice Address - State:IN
Practice Address - Zip Code:47265-1723
Practice Address - Country:US
Practice Address - Phone:812-346-4834
Practice Address - Fax:812-346-7058
Is Sole Proprietor?:No
Enumeration Date:2011-09-05
Last Update Date:2011-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26016862A183500000X
FLPS22922183500000X
MAPH19932183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN26016862AOtherPHARMACIST STATE LISCENSE