MEDICARE: TJT 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	183500000X	Pharmacist		IL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	212195	OTHER	IL	MEDICARE LEGACY NUMBER

General Provider Information

NPI Number	:	1871587642
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TJT PHARMACY, INC

Provider Business Mailing Address
First Line	:	1016 4TH ST
Second Line	:
City	:	FULTON
State	:	IL
Zip	:	61252-1716
Country	:	US
Telephone Number	:	815-589-2233
Fax Number	:	815-589-4789

Provider Business Practice Location Address
First Line	:	1016 4TH ST
Second Line	:
City	:	FULTON
State	:	IL
Zip	:	61252-1716
Country	:	US
Telephone Number	:	815-589-2233
Fax Number	:	815-589-4789

Authorized Official
Title or Position	:	PRESIDENT
Name	:	TERRY TUFTY
Credential	:
Telephone Number	:	815-589-2233

Provider Enumeration Date	:	09/07/2005
Last Update Date	:	12/03/2007

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