Provider Demographics
NPI:1053606228
Name:TERRELL, CLENNY EDWARD (RPH)
Entity type:Individual
Prefix:
First Name:CLENNY
Middle Name:EDWARD
Last Name:TERRELL
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1276
Mailing Address - Street 2:
Mailing Address - City:WHITNEY
Mailing Address - State:TX
Mailing Address - Zip Code:76692-1276
Mailing Address - Country:US
Mailing Address - Phone:254-675-4047
Mailing Address - Fax:
Practice Address - Street 1:1520 S. VALLEY MILLS DR.
Practice Address - Street 2:
Practice Address - City:BEVELY HILLS
Practice Address - State:TX
Practice Address - Zip Code:76711
Practice Address - Country:US
Practice Address - Phone:254-752-3986
Practice Address - Fax:254-752-4097
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-15
Last Update Date:2011-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX20523183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist