Provider Demographics
NPI:1023148632
Name:TERRY R DANIELS
Entity type:Organization
Organization Name:TERRY R DANIELS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER PHARMACIST SECRETARY JANITOR
Authorized Official - Prefix:DR
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:R
Authorized Official - Last Name:DANIELS
Authorized Official - Suffix:
Authorized Official - Credentials:PD MDIV
Authorized Official - Phone:260-375-2135
Mailing Address - Street 1:PO BOX 345
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:IN
Mailing Address - Zip Code:46792-0345
Mailing Address - Country:US
Mailing Address - Phone:260-375-2135
Mailing Address - Fax:
Practice Address - Street 1:222 N WAYNE ST
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:IN
Practice Address - Zip Code:46792-0345
Practice Address - Country:US
Practice Address - Phone:260-375-2135
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-06
Last Update Date:2009-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN60004799A333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200022820AMedicaid
IN200022820Medicaid