Provider Demographics
NPI:1073783080
Name:SMALL, TINA M (RPH)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:M
Last Name:SMALL
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 1:189 PICKET POST LN
Mailing Address - Street 2:
Mailing Address - City:PHOENIXVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:19460-5619
Mailing Address - Country:US
Mailing Address - Phone:610-933-7856
Mailing Address - Fax:
Practice Address - Street 1:3400 SPRUCE ST
Practice Address - Street 2:RAVDIN1
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-4206
Practice Address - Country:US
Practice Address - Phone:215-662-2920
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-05
Last Update Date:2008-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP041390L183500000X
NJRI26065183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJRI26065OtherRPH STATE LICENSE NUMBER
PARP041390LOtherRPH STATE LICENSE NUMBER