Provider Demographics
NPI:1467964809
Name:MUCKEROY, TELFIA YVETTE (RPH)
Entity Type:Individual
Prefix:MS
First Name:TELFIA
Middle Name:YVETTE
Last Name:MUCKEROY
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2502 RIVERSIDE PKWY APT 1028
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75050-7982
Mailing Address - Country:US
Mailing Address - Phone:469-662-6752
Mailing Address - Fax:
Practice Address - Street 1:814 HONEA EGYPT RD STE 101
Practice Address - Street 2:
Practice Address - City:MAGNOLIA
Practice Address - State:TX
Practice Address - Zip Code:77354-3864
Practice Address - Country:US
Practice Address - Phone:281-974-2678
Practice Address - Fax:281-783-2436
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-25
Last Update Date:2023-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX32640183500000X, 1835P2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P2201XPharmacy Service ProvidersPharmacistAmbulatory Care
No183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX32640Medicaid
TX150188Medicaid