Healthcare Provider Details

I. General information

NPI: 1497347496
Provider Name (Legal Business Name): KATELYN TIDWELL PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/10/2021
Last Update Date: 02/10/2021
Certification Date: 02/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

688 BALDWIN AVE
DEFUNIAK SPRINGS FL
32435-2596
US

IV. Provider business mailing address

688 BALDWIN AVE
DEFUNIAK SPRINGS FL
32435-2596
US

V. Phone/Fax

Practice location:
  • Phone: 850-892-5612
  • Fax:
Mailing address:
  • Phone: 850-892-5612
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPS43999
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: