Provider Demographics
NPI:1114022308
Name:SMITH, TERESA F (RPH)
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:F
Last Name:SMITH
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:230 ELI RD
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE
Mailing Address - State:GA
Mailing Address - Zip Code:31321
Mailing Address - Country:US
Mailing Address - Phone:912-653-3356
Mailing Address - Fax:912-653-4585
Practice Address - Street 1:27 N MAIN ST
Practice Address - Street 2:
Practice Address - City:PEMBROKE
Practice Address - State:GA
Practice Address - Zip Code:31321
Practice Address - Country:US
Practice Address - Phone:912-653-4596
Practice Address - Fax:912-653-4585
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA15905183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00021832AMedicaid
GA0217660001Medicare NSC
GA0217660001Medicare ID - Type Unspecified
GA00021832AMedicaid