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NPI Code Detail

MEDICARE: JACK TIDABACK RPH

MEDICARE: JACK TIDABACK RPH
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
1183500000XPharmacist3118MT

General Provider Information

NPI Number : 1255329710
Entity Type Code : Individual
Provider Name (Legal Business Name) : JACK TIDABACK RPH
Provider Business Mailing Address
First Line : 214 14TH AVE SW
Second Line :
City : SIDNEY
State : MT
Zip : 59270-3521
Country : US
Telephone Number : 406-488-6563
Fax Number : 406-488-2231
Provider Business Practice Location Address
First Line : 214 14TH AVE SW
Second Line :
City : SIDNEY
State : MT
Zip : 59270-3521
Country : US
Telephone Number : 406-488-6563
Fax Number : 406-488-2231
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 10/10/2005
Last Update Date : 07/08/2007

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