Provider Demographics
NPI:1356774152
Name:TEAGUE, TERI JO
Entity type:Individual
Prefix:
First Name:TERI
Middle Name:JO
Last Name:TEAGUE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TERI
Other - Middle Name:JO
Other - Last Name:SHACKELFORD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:205 MILLSTONE CIR
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37042-5931
Mailing Address - Country:US
Mailing Address - Phone:931-237-2107
Mailing Address - Fax:
Practice Address - Street 1:205 MILLSTONE CIR
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37042-5931
Practice Address - Country:US
Practice Address - Phone:931-237-2107
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-15
Last Update Date:2013-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN42783183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0000042783OtherSTATE OF TENNESSEE DEPT OF HEALTH