MEDICARE: JACQUELINE RENEE TEWELL

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	PS60363	FL

General Provider Information

NPI Number	:	1982244810
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACQUELINE RENEE TEWELL

Provider Business Mailing Address
First Line	:	3390 CAMERON CHASE DR
Second Line	:
City	:	TALLAHASSEE
State	:	FL
Zip	:	32309-2872
Country	:	US
Telephone Number	:	850-980-0085
Fax Number	:

Provider Business Practice Location Address
First Line	:	3122 MAHAN DR
Second Line	:
City	:	TALLAHASSEE
State	:	FL
Zip	:	32308-2500
Country	:	US
Telephone Number	:	840-402-0808
Fax Number	:

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

Provider Enumeration Date	:	01/08/2020
Last Update Date	:	01/08/2020

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