Provider Demographics
NPI:1417602004
Name:TERRY, MELODY E
Entity type:Individual
Prefix:
First Name:MELODY
Middle Name:E
Last Name:TERRY
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 1:123 PIEDMONT AVE APT B
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27101-3638
Mailing Address - Country:US
Mailing Address - Phone:910-206-4410
Mailing Address - Fax:
Practice Address - Street 1:5322 US HIGHWAY 158
Practice Address - Street 2:
Practice Address - City:ADVANCE
Practice Address - State:NC
Practice Address - Zip Code:27006-6907
Practice Address - Country:US
Practice Address - Phone:336-940-5515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-13
Last Update Date:2022-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC31037183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist