MEDICARE: TDS PHARMACY, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332B00000X	Durable Medical Equipment & Medical Supplies	CME-0132501	MI

General Provider Information

NPI Number	:	1073771002
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TDS PHARMACY, INC.

Provider Business Mailing Address
First Line	:	21 W SANILAC RD
Second Line	:
City	:	SANDUSKY
State	:	MI
Zip	:	48471
Country	:	US
Telephone Number	:	800-922-5101
Fax Number	:	866-303-2221

Provider Business Practice Location Address
First Line	:	4482 W HOUGHTON LAKE DR
Second Line	:	UNIT 1 BLDG A
City	:	HOUGHTON LAKE
State	:	MI
Zip	:	48629-8361
Country	:	US
Telephone Number	:	989-422-6544
Fax Number	:	989-422-6500

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. TIMOTHY SHELDON
Credential	:	RPH
Telephone Number	:	810-989-1340

Provider Enumeration Date	:	05/27/2008
Last Update Date	:	05/16/2011

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