Healthcare Provider Details

I. General information

NPI: 1396827184
Provider Name (Legal Business Name): TJD ENTERPRISES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2006
Last Update Date: 07/15/2021
Certification Date: 07/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 E MAIN ST
MC LEANSBORO IL
62859-1460
US

IV. Provider business mailing address

107 E MAIN ST
MC LEANSBORO IL
62859-1460
US

V. Phone/Fax

Practice location:
  • Phone: 618-643-3524
  • Fax: 618-643-2315
Mailing address:
  • Phone: 618-643-3524
  • Fax: 618-643-2315

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number054.015034
License Number StateIL

VIII. Authorized Official

Name: KEITH DOEHRING
Title or Position: OWNER
Credential: PHARM D
Phone: 618-214-2209