Provider Demographics
NPI:1063474807
Name:TIDWELL, JANET (RPH)
Entity Type:Individual
Prefix:
First Name:JANET
Middle Name:
Last Name:TIDWELL
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 W FRONT ST
Mailing Address - Street 2:
Mailing Address - City:DE KALB
Mailing Address - State:TX
Mailing Address - Zip Code:75559-1308
Mailing Address - Country:US
Mailing Address - Phone:903-667-0880
Mailing Address - Fax:903-667-0909
Practice Address - Street 1:120 W FRONT ST
Practice Address - Street 2:
Practice Address - City:DE KALB
Practice Address - State:TX
Practice Address - Zip Code:75559-1308
Practice Address - Country:US
Practice Address - Phone:903-667-0880
Practice Address - Fax:903-667-0909
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2007-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX23634183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist