1811281181 NPI number — DR. KRISTOPHER RICHARD TIDWELL PHARMD

Table of content: DR. KRISTOPHER RICHARD TIDWELL PHARMD (NPI 1811281181)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811281181 NPI number — DR. KRISTOPHER RICHARD TIDWELL PHARMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TIDWELL
Provider First Name:
KRISTOPHER
Provider Middle Name:
RICHARD
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PHARMD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1811281181
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/14/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1106 N COLUMBIA CENTER BLVD
Provider Second Line Business Mailing Address:
TARGET PHARMACY - T0830
Provider Business Mailing Address City Name:
KENNEWICK
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
99336-1161
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-737-1700
Provider Business Mailing Address Fax Number:
509-378-3653

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1106 N COLUMBIA CENTER BLVD
Provider Second Line Business Practice Location Address:
TARGET PHARMACY - T0830
Provider Business Practice Location Address City Name:
KENNEWICK
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99336-1161
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-737-1700
Provider Business Practice Location Address Fax Number:
509-378-3653
Provider Enumeration Date:
06/04/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  PH 60173826 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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