Provider Demographics
NPI:1659649465
Name:HUSTAD, TERRY J (RPH)
Entity Type:Individual
Prefix:MR
First Name:TERRY
Middle Name:J
Last Name:HUSTAD
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 1:108 COTTAGE GROVE RD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53716-1104
Mailing Address - Country:US
Mailing Address - Phone:608-222-8651
Mailing Address - Fax:608-222-2184
Practice Address - Street 1:108 COTTAGE GROVE RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53716-1104
Practice Address - Country:US
Practice Address - Phone:608-222-8651
Practice Address - Fax:608-222-2184
Is Sole Proprietor?:No
Enumeration Date:2011-12-07
Last Update Date:2011-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9506183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist