Provider Demographics
NPI:1427041870
Name:LIDDIL, TERRA H (RPH, PHARMD)
Entity Type:Individual
Prefix:DR
First Name:TERRA
Middle Name:H
Last Name:LIDDIL
Suffix:
Gender:F
Credentials:RPH, PHARMD
Other - Prefix:DR
Other - First Name:TERRA
Other - Middle Name:H
Other - Last Name:LIDDIL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RPH, PHARMD
Mailing Address - Street 1:812 5TH ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NM
Mailing Address - Zip Code:87701-4330
Mailing Address - Country:US
Mailing Address - Phone:505-425-3770
Mailing Address - Fax:
Practice Address - Street 1:812 5TH ST
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NM
Practice Address - Zip Code:87701-4330
Practice Address - Country:US
Practice Address - Phone:505-425-3770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-31
Last Update Date:2013-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPC00000096183500000X
NMRP00005165183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist