Provider Demographics
NPI:1023243284
Name:NELSON, TERRY A (RPH)
Entity type:Individual
Prefix:
First Name:TERRY
Middle Name:A
Last Name:NELSON
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 1:7670 FAIRVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-8415
Mailing Address - Country:US
Mailing Address - Phone:208-376-0053
Mailing Address - Fax:208-376-4759
Practice Address - Street 1:7670 FAIRVIEW AVE
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8415
Practice Address - Country:US
Practice Address - Phone:208-376-0053
Practice Address - Fax:208-376-4759
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-18
Last Update Date:2009-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP4019183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDP4019Other183500000X