Provider Demographics
NPI:1972742757
Name:PORTER, THERESA DENISE
Entity type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:DENISE
Last Name:PORTER
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 1:11515 ADAMS DR
Mailing Address - Street 2:
Mailing Address - City:CATLETTSBURG
Mailing Address - State:KY
Mailing Address - Zip Code:41129-9700
Mailing Address - Country:US
Mailing Address - Phone:606-929-4118
Mailing Address - Fax:606-929-4392
Practice Address - Street 1:11515 ADAMS DR
Practice Address - Street 2:
Practice Address - City:CATLETTSBURG
Practice Address - State:KY
Practice Address - Zip Code:41129-9700
Practice Address - Country:US
Practice Address - Phone:606-929-4118
Practice Address - Fax:606-929-4392
Is Sole Proprietor?:No
Enumeration Date:2009-02-18
Last Update Date:2009-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY009469183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist