Provider Demographics
NPI:1063799559
Name:HURST, THERESA
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:HURST
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 1:990 E 700 N
Mailing Address - Street 2:
Mailing Address - City:DELPHI
Mailing Address - State:IN
Mailing Address - Zip Code:46923-8374
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2301 E MARKET ST
Practice Address - Street 2:
Practice Address - City:LOGANSPORT
Practice Address - State:IN
Practice Address - Zip Code:46947-2037
Practice Address - Country:US
Practice Address - Phone:574-735-3815
Practice Address - Fax:574-739-0824
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-10
Last Update Date:2011-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26018056A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist