Provider Demographics
NPI:1497110878
Name:DICK, TERAH (CPHT)
Entity Type:Individual
Prefix:
First Name:TERAH
Middle Name:
Last Name:DICK
Suffix:
Gender:F
Credentials:CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1454 E REPUBLIC RD
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-6507
Mailing Address - Country:US
Mailing Address - Phone:417-886-6880
Mailing Address - Fax:
Practice Address - Street 1:1454 E REPUBLIC RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-6507
Practice Address - Country:US
Practice Address - Phone:417-886-6880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-29
Last Update Date:2015-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO1999136438183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician