Provider Demographics
NPI:1396827184
Name:TJD ENTERPRISES LLC
Entity Type:Organization
Organization Name:TJD ENTERPRISES LLC
Other - Org Name:YORK PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:
Authorized Official - Last Name:DOEHRING
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:618-214-2209
Mailing Address - Street 1:107 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MC LEANSBORO
Mailing Address - State:IL
Mailing Address - Zip Code:62859-1460
Mailing Address - Country:US
Mailing Address - Phone:618-643-3524
Mailing Address - Fax:618-643-2315
Practice Address - Street 1:107 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MC LEANSBORO
Practice Address - State:IL
Practice Address - Zip Code:62859-1460
Practice Address - Country:US
Practice Address - Phone:618-643-3524
Practice Address - Fax:618-643-2315
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2021-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
291U00000X, 333600000X
IL054.0150343336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No291U00000XLaboratoriesClinical Medical Laboratory
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2022663OtherPK
IL=========001Medicaid
5100910001Medicare NSC