Provider Demographics
NPI:1497350656
Name:KRUSE, TERESA
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:KRUSE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1417 TERRALAGO PL
Mailing Address - Street 2:
Mailing Address - City:OVIEDO
Mailing Address - State:FL
Mailing Address - Zip Code:32765-3714
Mailing Address - Country:US
Mailing Address - Phone:214-629-3548
Mailing Address - Fax:
Practice Address - Street 1:4062 LYNDON B JOHNSON FWY
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75244-5701
Practice Address - Country:US
Practice Address - Phone:972-759-6495
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-03
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX35416183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist