Provider Demographics
NPI:1891479606
Name:BASS, TERRELL
Entity type:Individual
Prefix:
First Name:TERRELL
Middle Name:
Last Name:BASS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:716 RICHMOND HWY APT 10113
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23224-5275
Mailing Address - Country:US
Mailing Address - Phone:804-999-1886
Mailing Address - Fax:
Practice Address - Street 1:1214 WESTOVER HILLS BLVD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23225-4434
Practice Address - Country:US
Practice Address - Phone:804-230-6335
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-12
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician