Provider Demographics
NPI:1396026647
Name:WAGGONER, TERRY L (PHARMACIST)
Entity Type:Individual
Prefix:MR
First Name:TERRY
Middle Name:L
Last Name:WAGGONER
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4212 ELVIS PRESLEY BLVD
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38116-6424
Mailing Address - Country:US
Mailing Address - Phone:901-332-4997
Mailing Address - Fax:901-398-5242
Practice Address - Street 1:4212 ELVIS PRESLEY BLVD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38116-6424
Practice Address - Country:US
Practice Address - Phone:901-332-4997
Practice Address - Fax:901-398-5242
Is Sole Proprietor?:No
Enumeration Date:2011-08-31
Last Update Date:2011-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN4247183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist