Provider Demographics
NPI:1629358171
Name:ALI, TERRANCE MOHAMED
Entity Type:Individual
Prefix:MR
First Name:TERRANCE
Middle Name:MOHAMED
Last Name:ALI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45549 HIGHWAY 27
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:FL
Mailing Address - Zip Code:33897-4519
Mailing Address - Country:US
Mailing Address - Phone:863-420-6120
Mailing Address - Fax:863-420-6112
Practice Address - Street 1:45549 HIGHWAY 27
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:FL
Practice Address - Zip Code:33897-4519
Practice Address - Country:US
Practice Address - Phone:863-420-6120
Practice Address - Fax:863-420-6112
Is Sole Proprietor?:No
Enumeration Date:2011-08-27
Last Update Date:2011-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS35713183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist