Healthcare Provider Details

I. General information

NPI: 1205348356
Provider Name (Legal Business Name): TNT APOTHECARY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/30/2017
Last Update Date: 06/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 IDAHO AVE
GLENNS FERRY ID
83623
US

IV. Provider business mailing address

PO BOX 487
WENDELL ID
83355-0487
US

V. Phone/Fax

Practice location:
  • Phone: 208-536-5761
  • Fax:
Mailing address:
  • Phone: 208-536-5761
  • Fax: 208-536-5852

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: THOMAS GILL WADSWORTH
Title or Position: OWNER
Credential:
Phone: 907-786-6211