Provider Demographics
NPI:1255329710
Name:TIDABACK, JACK (RPH)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:TIDABACK
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:214 14TH AVE SW
Mailing Address - Street 2:
Mailing Address - City:SIDNEY
Mailing Address - State:MT
Mailing Address - Zip Code:59270-3521
Mailing Address - Country:US
Mailing Address - Phone:406-488-6563
Mailing Address - Fax:406-488-2231
Practice Address - Street 1:214 14TH AVE SW
Practice Address - Street 2:
Practice Address - City:SIDNEY
Practice Address - State:MT
Practice Address - Zip Code:59270-3521
Practice Address - Country:US
Practice Address - Phone:406-488-6563
Practice Address - Fax:406-488-2231
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT3118183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist