Provider Demographics
NPI:1609132083
Name:OCONNELL, TERRY LEE (PHARMACIST)
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:LEE
Last Name:OCONNELL
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:146 LUKESPORT DR
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:MI
Mailing Address - Zip Code:49082-9595
Mailing Address - Country:US
Mailing Address - Phone:517-639-8453
Mailing Address - Fax:
Practice Address - Street 1:237 E. CHICAGO ST.
Practice Address - Street 2:
Practice Address - City:JONESVILLE
Practice Address - State:MI
Practice Address - Zip Code:49025
Practice Address - Country:US
Practice Address - Phone:517-849-9804
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-10
Last Update Date:2012-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302020168183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5302020168OtherMICHIGAN PHARMACIST LICENSE