Provider Demographics
NPI:1275823627
Name:TIDWELL, REBECCA (PHARMD)
Entity Type:Individual
Prefix:MISS
First Name:REBECCA
Middle Name:
Last Name:TIDWELL
Suffix:
Gender:F
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:PO BOX 357
Mailing Address - Street 2:
Mailing Address - City:WELLPINIT
Mailing Address - State:WA
Mailing Address - Zip Code:99040-0357
Mailing Address - Country:US
Mailing Address - Phone:509-258-4517
Mailing Address - Fax:
Practice Address - Street 1:6203 AGENCY LOOP
Practice Address - Street 2:
Practice Address - City:WELLPINIT
Practice Address - State:WA
Practice Address - Zip Code:99040
Practice Address - Country:US
Practice Address - Phone:509-258-4517
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-19
Last Update Date:2011-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT6280183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist