Healthcare Provider Details

I. General information

NPI: 1316029184
Provider Name (Legal Business Name): TNT APOTHECARY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2006
Last Update Date: 07/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

280 S IDAHO ST
WENDELL ID
83355-5200
US

IV. Provider business mailing address

PO BOX 487
WENDELL ID
83355-0487
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number2335CP
License Number StateID

VIII. Authorized Official

Name: THOMAS WADSWORTH
Title or Position: OWNER/MANAGER
Credential: RPH
Phone: 208-536-5761