Provider Demographics
NPI:1114563020
Name:TIDWELL, JERROD (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:JERROD
Middle Name:
Last Name:TIDWELL
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 AVALON AVE
Mailing Address - Street 2:
Mailing Address - City:MUSCLE SHOALS
Mailing Address - State:AL
Mailing Address - Zip Code:35661-2401
Mailing Address - Country:US
Mailing Address - Phone:256-381-8060
Mailing Address - Fax:256-381-8065
Practice Address - Street 1:1001 AVALON AVE
Practice Address - Street 2:
Practice Address - City:MUSCLE SHOALS
Practice Address - State:AL
Practice Address - Zip Code:35661-2401
Practice Address - Country:US
Practice Address - Phone:256-381-8060
Practice Address - Fax:256-381-8065
Is Sole Proprietor?:No
Enumeration Date:2019-11-26
Last Update Date:2019-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL18828183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist