MEDICARE: DR. JOHN TEDDER PHARM D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	2013024727	MO

General Provider Information

NPI Number	:	1043676927
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOHN TEDDER PHARM D.

Provider Business Mailing Address
First Line	:	5488 MYSTIC OAKS DR
Second Line	:
City	:	IMPERIAL
State	:	MO
Zip	:	63052-3433
Country	:	US
Telephone Number	:	636-322-9266
Fax Number	:

Provider Business Practice Location Address
First Line	:	1025 E HIGHWAY 72 BYP
Second Line	:
City	:	FREDERICKTOWN
State	:	MO
Zip	:	63645-7326
Country	:	US
Telephone Number	:	573-783-6000
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/08/2016
Last Update Date	:	01/08/2016

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