Provider Demographics
NPI:1740531235
Name:CUSACK, TERENCE JOSEPH IV
Entity type:Individual
Prefix:
First Name:TERENCE
Middle Name:JOSEPH
Last Name:CUSACK
Suffix:IV
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 1:401 HOLLAND LN
Mailing Address - Street 2:513
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22314-3428
Mailing Address - Country:US
Mailing Address - Phone:760-464-8022
Mailing Address - Fax:
Practice Address - Street 1:1145 STURGIS STREET
Practice Address - Street 2:
Practice Address - City:TWENTYNINE PALMS
Practice Address - State:CA
Practice Address - Zip Code:92277
Practice Address - Country:US
Practice Address - Phone:760-830-2202
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-25
Last Update Date:2022-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA672151835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy