MEDICARE: TNT APOTHECARY LLC

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	3336C0003X	Community/Retail Pharmacy

General Provider Information

NPI Number	:	1205348356
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TNT APOTHECARY LLC

Provider Business Mailing Address
First Line	:	PO BOX 487
Second Line	:
City	:	WENDELL
State	:	ID
Zip	:	83355-0487
Country	:	US
Telephone Number	:	208-536-5761
Fax Number	:	208-536-5852

Provider Business Practice Location Address
First Line	:	30 IDAHO AVE
Second Line	:
City	:	GLENNS FERRY
State	:	ID
Zip	:	83623
Country	:	US
Telephone Number	:	208-536-5761
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	THOMAS GILL WADSWORTH
Credential	:
Telephone Number	:	907-786-6211

Provider Enumeration Date	:	10/30/2017
Last Update Date	:	06/16/2018

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