Provider Demographics
NPI:1639779812
Name:SIRIBANDAN, TERRY
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:
Last Name:SIRIBANDAN
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 1:19212 E KNIGHTSBRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:OWASSO
Mailing Address - State:OK
Mailing Address - Zip Code:74055-8133
Mailing Address - Country:US
Mailing Address - Phone:918-557-1693
Mailing Address - Fax:
Practice Address - Street 1:1500 S LYNN RIGGS BLVD
Practice Address - Street 2:
Practice Address - City:CLAREMORE
Practice Address - State:OK
Practice Address - Zip Code:74017-8399
Practice Address - Country:US
Practice Address - Phone:918-341-5181
Practice Address - Fax:918-341-4888
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-28
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK10249183500000X
CA35429183500000X
NV7951183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist