Provider Demographics
NPI:1912282716
Name:MCKETTRICK, TERRI F
Entity Type:Individual
Prefix:MRS
First Name:TERRI
Middle Name:F
Last Name:MCKETTRICK
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 1:2215 MORNINGSIDE DR
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30904-3441
Mailing Address - Country:US
Mailing Address - Phone:706-736-9672
Mailing Address - Fax:
Practice Address - Street 1:2744 WASHINGTON RD
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-2218
Practice Address - Country:US
Practice Address - Phone:706-733-4277
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-12
Last Update Date:2011-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA13389183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist