Provider Demographics
NPI:1366889867
Name:SPARKS, TERA
Entity type:Individual
Prefix:
First Name:TERA
Middle Name:
Last Name:SPARKS
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 1:1019 CUMBERLAND FALLS HWY
Mailing Address - Street 2:
Mailing Address - City:CORBIN
Mailing Address - State:KY
Mailing Address - Zip Code:40701-2735
Mailing Address - Country:US
Mailing Address - Phone:606-526-0755
Mailing Address - Fax:
Practice Address - Street 1:1019 CUMBERLAND FALLS HWY
Practice Address - Street 2:
Practice Address - City:CORBIN
Practice Address - State:KY
Practice Address - Zip Code:40701-2735
Practice Address - Country:US
Practice Address - Phone:606-526-0755
Practice Address - Fax:606-526-9589
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-24
Last Update Date:2013-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY014582183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY014582OtherSTATE LICENSE NUMBER