Provider Demographics
NPI:1952888513
Name:REVELL, TERESA (PHARMD)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:REVELL
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:TERESA
Other - Middle Name:
Other - Last Name:MILNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:100 DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:ANSONIA
Mailing Address - State:CT
Mailing Address - Zip Code:06401-2147
Mailing Address - Country:US
Mailing Address - Phone:203-732-3907
Mailing Address - Fax:
Practice Address - Street 1:100 DIVISION ST
Practice Address - Street 2:
Practice Address - City:ANSONIA
Practice Address - State:CT
Practice Address - Zip Code:06401-2147
Practice Address - Country:US
Practice Address - Phone:203-732-3907
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-25
Last Update Date:2018-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0012246183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTPCT.0012246OtherDEPARTMENT OF CONSUMER AFFAIRS, CONNECTICUT