=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366576811
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TIDWELL PROFESSION PHARMACY INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/15/2007
-----------------------------------------------------
Last Update Date | 06/21/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2310 TIDWELL RD
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77093-6731
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-694-5977
-----------------------------------------------------
Fax | 713-694-2450
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2310 TIDWELL RD
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77093-6731
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-694-5977
-----------------------------------------------------
Fax | 713-694-2450
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER PHARMACIST
-----------------------------------------------------
Name | MS. NORMA CASTELLANOS
-----------------------------------------------------
Credential | RPH
-----------------------------------------------------
Telephone | 713-694-5977
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 22194
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------