Provider Demographics
NPI:1043669385
Name:TERRY, LISA FOX (PD)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:FOX
Last Name:TERRY
Suffix:
Gender:F
Credentials:PD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 RIVER ROAD DR W
Mailing Address - Street 2:
Mailing Address - City:MAYFLOWER
Mailing Address - State:AR
Mailing Address - Zip Code:72106-8426
Mailing Address - Country:US
Mailing Address - Phone:501-554-6168
Mailing Address - Fax:
Practice Address - Street 1:116 RIVER ROAD DR W
Practice Address - Street 2:
Practice Address - City:MAYFLOWER
Practice Address - State:AR
Practice Address - Zip Code:72106-8426
Practice Address - Country:US
Practice Address - Phone:501-554-6168
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-07
Last Update Date:2016-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD06944183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist