Provider Demographics
NPI:1558596718
Name:TIBBETTS, TERRY EUGENE (RPH)
Entity Type:Individual
Prefix:MR
First Name:TERRY
Middle Name:EUGENE
Last Name:TIBBETTS
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5974 PENTZ RD
Mailing Address - Street 2:
Mailing Address - City:PARADISE
Mailing Address - State:CA
Mailing Address - Zip Code:95969-5509
Mailing Address - Country:US
Mailing Address - Phone:530-876-7177
Mailing Address - Fax:530-876-2137
Practice Address - Street 1:5974 PENTZ RD
Practice Address - Street 2:
Practice Address - City:PARADISE
Practice Address - State:CA
Practice Address - Zip Code:95969-5509
Practice Address - Country:US
Practice Address - Phone:530-876-7177
Practice Address - Fax:530-876-2137
Is Sole Proprietor?:No
Enumeration Date:2009-05-18
Last Update Date:2009-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA29036183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARWGMedicaid