MEDICARE: DR. TIDDY MAUTI PHARMD

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	RP455059	PA

General Provider Information

NPI Number	:	1255926432
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TIDDY MAUTI PHARMD

Provider Business Mailing Address
First Line	:	3300 S BROAD ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19145-5802
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3300 S BROAD ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19145-5802
Country	:	US
Telephone Number	:	215-463-0891
Fax Number	:

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

Provider Enumeration Date	:	03/09/2021
Last Update Date	:	03/09/2021

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