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General NPI Number Information
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NPI Number | 1588900773
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Entity Type | Individual
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Provider Name | HEATHER ANGELICA TIDWELL PHARM.D.
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Gender | Female
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Dates
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Enumeration Date | 12/17/2012
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Last Update Date | 12/17/2012
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Provider Practice Location Address
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Address Line | 2930 N 67TH AVE
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City | PHOENIX
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State | AZ
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Zip | 85033-5610
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Country | US
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Telephone | 623-849-6991
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Fax |
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Provider Business Mailing Address
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Address Line | 4502 E SAN GABRIEL AVE
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City | PHOENIX
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State | AZ
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Zip | 85044-1429
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Country | US
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Telephone | 404-542-1626
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | S019535
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License Number State | AZ
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