Provider Demographics
NPI:1871861948
Name:FAHLENKAMP, TERRANCE TYRONE (PHARMACIST)
Entity Type:Individual
Prefix:
First Name:TERRANCE
Middle Name:TYRONE
Last Name:FAHLENKAMP
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 1:4826 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265
Mailing Address - Country:US
Mailing Address - Phone:309-762-1135
Mailing Address - Fax:
Practice Address - Street 1:1009 S OAKWOOD AVE
Practice Address - Street 2:
Practice Address - City:GENESEO
Practice Address - State:IL
Practice Address - Zip Code:61254-1937
Practice Address - Country:US
Practice Address - Phone:309-944-3784
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-05
Last Update Date:2011-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.037640183500000X
IA13590183500000X
CO11249183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist