Provider Demographics
NPI:1982701447
Name:WHITTEN, TERRY DALE
Entity type:Individual
Prefix:
First Name:TERRY
Middle Name:DALE
Last Name:WHITTEN
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 1:3563 PHILLIPS HWY
Mailing Address - Street 2:BLD B, STE 202
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-5663
Mailing Address - Country:US
Mailing Address - Phone:904-202-4425
Mailing Address - Fax:904-398-2225
Practice Address - Street 1:3563 PHILLIPS HWY
Practice Address - Street 2:STE. 200
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-5663
Practice Address - Country:US
Practice Address - Phone:904-202-4425
Practice Address - Fax:904-398-2225
Is Sole Proprietor?:No
Enumeration Date:2006-09-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS22298183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist