Provider Demographics
NPI:1801117064
Name:TETTEY, VICTORIA M
Entity type:Individual
Prefix:MS
First Name:VICTORIA
Middle Name:M
Last Name:TETTEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30007 S LAKE FALLS CIR
Mailing Address - Street 2:
Mailing Address - City:SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:77386-2897
Mailing Address - Country:US
Mailing Address - Phone:281-292-9236
Mailing Address - Fax:
Practice Address - Street 1:19215 I-45 SOUTH
Practice Address - Street 2:
Practice Address - City:SHENANDOAH
Practice Address - State:TX
Practice Address - Zip Code:77385
Practice Address - Country:US
Practice Address - Phone:281-419-5158
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-22
Last Update Date:2012-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX426831835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1649287566Medicaid