Healthcare Provider Details

I. General information

NPI: 1043676927
Provider Name (Legal Business Name): JOHN TEDDER PHARM D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/08/2016
Last Update Date: 01/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1025 E HIGHWAY 72 BYP
FREDERICKTOWN MO
63645-7326
US

IV. Provider business mailing address

5488 MYSTIC OAKS DR
IMPERIAL MO
63052-3433
US

V. Phone/Fax

Practice location:
  • Phone: 573-783-6000
  • Fax:
Mailing address:
  • Phone: 636-322-9266
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number2013024727
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: