Healthcare Provider Details

I. General information

NPI: 1912650268
Provider Name (Legal Business Name): DESTIN TIDWELL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/27/2022
Last Update Date: 07/01/2025
Certification Date: 07/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5530 THREE NOTCH RD
MOBILE AL
36619-1714
US

IV. Provider business mailing address

9650 HAMILTON CREEK DR S
MOBILE AL
36695-9305
US

V. Phone/Fax

Practice location:
  • Phone: 251-666-0249
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number23733
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: