Provider Demographics
NPI:1376062547
Name:HUBENKA, TERRANCE
Entity Type:Individual
Prefix:
First Name:TERRANCE
Middle Name:
Last Name:HUBENKA
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 1:634 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LANDER
Mailing Address - State:WY
Mailing Address - Zip Code:82520-3034
Mailing Address - Country:US
Mailing Address - Phone:307-332-2270
Mailing Address - Fax:307-332-6007
Practice Address - Street 1:634 MAIN ST
Practice Address - Street 2:
Practice Address - City:LANDER
Practice Address - State:WY
Practice Address - Zip Code:82520-3034
Practice Address - Country:US
Practice Address - Phone:307-332-2270
Practice Address - Fax:307-332-6007
Is Sole Proprietor?:No
Enumeration Date:2017-09-19
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY2053183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist