Provider Demographics
NPI:1497053615
Name:BAIN, TERRY LEWIS
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:LEWIS
Last Name:BAIN
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 1:130 FILBERT RUN
Mailing Address - Street 2:
Mailing Address - City:FREEHOLD
Mailing Address - State:NJ
Mailing Address - Zip Code:07728-4115
Mailing Address - Country:US
Mailing Address - Phone:732-409-0885
Mailing Address - Fax:
Practice Address - Street 1:3258 BRIDGE AVE
Practice Address - Street 2:
Practice Address - City:POINT PLEASANT BORO
Practice Address - State:NJ
Practice Address - Zip Code:08742-3459
Practice Address - Country:US
Practice Address - Phone:732-892-5673
Practice Address - Fax:732-892-4457
Is Sole Proprietor?:No
Enumeration Date:2011-03-11
Last Update Date:2011-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI01324100183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist