Provider Demographics
NPI:1346295367
Name:MADDOX, TERRY MICHAEL (PHARM D)
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:MICHAEL
Last Name:MADDOX
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1833 KINGSHIGHWAY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:WASHINGTON PARK
Mailing Address - State:IL
Mailing Address - Zip Code:62204-2135
Mailing Address - Country:US
Mailing Address - Phone:618-874-3000
Mailing Address - Fax:618-874-3019
Practice Address - Street 1:1833 KINGSHIGHWAY
Practice Address - Street 2:SUITE 200
Practice Address - City:WASHINGTON PARK
Practice Address - State:IL
Practice Address - Zip Code:62204-2135
Practice Address - Country:US
Practice Address - Phone:618-874-3000
Practice Address - Fax:618-874-3019
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist