MEDICARE: ROBERT C TISDALE RPH

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	183500000X	Pharmacist	0202004217	VA

General Provider Information

NPI Number	:	1558350769
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROBERT C TISDALE RPH

Provider Business Mailing Address
First Line	:	2610 NORTHWIND DR
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23233-3313
Country	:	US
Telephone Number	:	804-360-4019
Fax Number	:

Provider Business Practice Location Address
First Line	:	5700 BROOK RD
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23227-2257
Country	:	US
Telephone Number	:	804-264-1597
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/19/2005
Last Update Date	:	07/08/2007

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