MEDICARE: TIDWELL PROFESSION 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	3336C0003X	Community/Retail Pharmacy	22194	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1366576811
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TIDWELL PROFESSION PHARMACY INC

Provider Business Mailing Address
First Line	:	2310 TIDWELL RD
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77093-6731
Country	:	US
Telephone Number	:	713-694-5977
Fax Number	:	713-694-2450

Provider Business Practice Location Address
First Line	:	2310 TIDWELL RD
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77093-6731
Country	:	US
Telephone Number	:	713-694-5977
Fax Number	:	713-694-2450

Authorized Official
Title or Position	:	OWNER PHARMACIST
Name	:	MS. NORMA CASTELLANOS
Credential	:	RPH
Telephone Number	:	713-694-5977

Provider Enumeration Date	:	03/15/2007
Last Update Date	:	06/21/2018

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