Provider Demographics
NPI:1275932725
Name:TERBLANCHE, STEPHAN VIVIER
Entity Type:Individual
Prefix:
First Name:STEPHAN
Middle Name:VIVIER
Last Name:TERBLANCHE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1450 S YUMA PALMS PKWY
Mailing Address - Street 2:T-1450
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85365-1707
Mailing Address - Country:US
Mailing Address - Phone:923-343-7466
Mailing Address - Fax:
Practice Address - Street 1:1450 S YUMA PALMS PKWY
Practice Address - Street 2:T-1450
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85365-1707
Practice Address - Country:US
Practice Address - Phone:928-343-7466
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-21
Last Update Date:2014-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS018134183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist