Provider Demographics
NPI:1104564632
Name:TERRA, KATHY AUDREY (PHARMACY TECHNICIAN)
Entity type:Individual
Prefix:
First Name:KATHY
Middle Name:AUDREY
Last Name:TERRA
Suffix:
Gender:F
Credentials:PHARMACY TECHNICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10859 WALKER DR
Mailing Address - Street 2:
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95945-6912
Mailing Address - Country:US
Mailing Address - Phone:530-216-9163
Mailing Address - Fax:
Practice Address - Street 1:280 SIERRA COLLEGE DR STE 210
Practice Address - Street 2:
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-5769
Practice Address - Country:US
Practice Address - Phone:530-273-8452
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-24
Last Update Date:2022-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA136265183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician