Provider Demographics
NPI:1518941392
Name:ROBIN GODFREY TERRERO
Entity Type:Organization
Organization Name:ROBIN GODFREY TERRERO
Other - Org Name:WELLNESS STORE COMPOUNDING PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:
Authorized Official - First Name:ROBIN
Authorized Official - Middle Name:
Authorized Official - Last Name:TERRERO
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:423-476-4312
Mailing Address - Street 1:3555 KEITH ST NW STE 210
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:TN
Mailing Address - Zip Code:37312-4375
Mailing Address - Country:US
Mailing Address - Phone:423-476-4312
Mailing Address - Fax:423-476-7982
Practice Address - Street 1:3555 KEITH ST NW STE 210
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:TN
Practice Address - Zip Code:37312-4375
Practice Address - Country:US
Practice Address - Phone:423-476-4312
Practice Address - Fax:423-476-7982
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-05
Last Update Date:2013-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3223333600000X
3336C0003X, 3336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2092295OtherPK
TN1452909Medicaid
2092295OtherPK