Provider Demographics
NPI:1356926489
Name:LANDRUM, TERRY GLEN
Entity type:Individual
Prefix:
First Name:TERRY
Middle Name:GLEN
Last Name:LANDRUM
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 1:1210 C C WOODSON RD
Mailing Address - Street 2:
Mailing Address - City:EARLY
Mailing Address - State:TX
Mailing Address - Zip Code:76802-8204
Mailing Address - Country:US
Mailing Address - Phone:325-646-2500
Mailing Address - Fax:325-641-0357
Practice Address - Street 1:1210 C C WOODSON RD
Practice Address - Street 2:
Practice Address - City:EARLY
Practice Address - State:TX
Practice Address - Zip Code:76802-8204
Practice Address - Country:US
Practice Address - Phone:325-646-2500
Practice Address - Fax:325-641-0357
Is Sole Proprietor?:No
Enumeration Date:2021-03-10
Last Update Date:2021-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX27749183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist