Provider Demographics
NPI:1528128253
Name:CARLEY, TERRY (RPH)
Entity type:Individual
Prefix:MR
First Name:TERRY
Middle Name:
Last Name:CARLEY
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 N ELM ST
Mailing Address - Street 2:PO BOX 698
Mailing Address - City:AVOCA
Mailing Address - State:IA
Mailing Address - Zip Code:51521-0698
Mailing Address - Country:US
Mailing Address - Phone:712-343-6777
Mailing Address - Fax:712-343-2681
Practice Address - Street 1:102 N ELM ST
Practice Address - Street 2:
Practice Address - City:AVOCA
Practice Address - State:IA
Practice Address - Zip Code:51521-0698
Practice Address - Country:US
Practice Address - Phone:712-343-6777
Practice Address - Fax:712-343-2681
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-11
Last Update Date:2007-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA238183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0081174Medicaid
IA0081174Medicaid