Provider Demographics
NPI:1700871852
Name:TERRY'S PHARMACY INC
Entity type:Organization
Organization Name:TERRY'S PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRES.
Authorized Official - Prefix:MR
Authorized Official - First Name:TERRANCE
Authorized Official - Middle Name:D
Authorized Official - Last Name:GERLACH
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:503-288-4646
Mailing Address - Street 1:1719 NE 16TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97212-4422
Mailing Address - Country:US
Mailing Address - Phone:503-288-4646
Mailing Address - Fax:503-288-7200
Practice Address - Street 1:1719 NE 16TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97212-4422
Practice Address - Country:US
Practice Address - Phone:503-288-4646
Practice Address - Fax:503-288-7200
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-14
Last Update Date:2008-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRP0000443-CS333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR3807748OtherNABP NUMBER
ORRP0000443-CSOtherPHARMACY LICENSE NUMBER
OR059972Medicaid