Basic Information
| Provider Information | |||||||||
| NPI: | 1649366121 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TEETERS | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | EUGENE | ||||||||
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| Credential: | R.PH. B.S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 506 BRIDGE ST | ||||||||
| Address2: | |||||||||
| City: | WAVERLY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 45690 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 17273 ST RT 104 | ||||||||
| Address2: | |||||||||
| City: | CHILLICOTHE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 45601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7407731141 | ||||||||
| FaxNumber: | 7407727138 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 03-2-13174 | OH | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.