Basic Information
| Provider Information | |||||||||
| NPI: | 1134705585 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TERRY | ||||||||
| FirstName: | BRANDON | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | CPHT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 W MAIN ST #2548 | ||||||||
| Address2: | |||||||||
| City: | ABINGDON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 242102548 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6812388332 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 200 EMILY DR | ||||||||
| Address2: | |||||||||
| City: | CLARKSBURG | ||||||||
| State: | WV | ||||||||
| PostalCode: | 263015500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3049186056 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2021 | ||||||||
| LastUpdateDate: | 06/05/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183700000X | 0230037671 | VA | N | Pharmacy Service Providers | Pharmacy Technician | 183700000X | PT0010763 | WV | Y | Pharmacy Service Providers | Pharmacy Technician |
No ID Information.