Healthcare Provider Details

I. General information

NPI: 1477843670
Provider Name (Legal Business Name): TJD ENTERPRISES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2011
Last Update Date: 12/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18195 EULA MAE PKWY
CARLYLE IL
62231-6406
US

IV. Provider business mailing address

18195 EULA MAE PKWY
CARLYLE IL
62231-6406
US

V. Phone/Fax

Practice location:
  • Phone: 618-594-8385
  • Fax: 618-594-8591
Mailing address:
  • Phone: 618-594-8385
  • Fax: 618-594-8591

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number054.017720
License Number StateIL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1485792
Identifier TypeOTHER
Identifier State
Identifier IssuerNCPDP PROVIDER IDENTIFICATION NUMBER

VIII. Authorized Official

Name: CHARLES DOEHRING
Title or Position: CO-MANAGER
Credential:
Phone: 618-327-3214