Provider Demographics
NPI:1275720468
Name:COSTAKIS, TERRY S (RPH)
Entity Type:Individual
Prefix:MR
First Name:TERRY
Middle Name:S
Last Name:COSTAKIS
Suffix:
Gender:M
Credentials:RPH
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Other - Credentials:
Mailing Address - Street 1:H 2005 KNIGHT LANE NAVY MEDICINE SUPPORT COMMAND
Mailing Address - Street 2:ATTN: MEDICAL STAFF SERVICES BLDG.
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32212-0140
Mailing Address - Country:US
Mailing Address - Phone:904-542-7200
Mailing Address - Fax:843-228-5196
Practice Address - Street 1:H 2005 KNIGHT LANE NAVY MEDICINE SUPPORT COMMAND
Practice Address - Street 2:ATTN: MEDICAL STAFF SERVICES BLDG.
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32212-0140
Practice Address - Country:US
Practice Address - Phone:904-542-7200
Practice Address - Fax:843-228-5196
Is Sole Proprietor?:No
Enumeration Date:2007-10-02
Last Update Date:2010-02-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SC11701183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist