Provider Demographics
NPI:1477219772
Name:TIDWELL, TINA
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:TIDWELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13800 VETERANS WAY
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32827-7401
Mailing Address - Country:US
Mailing Address - Phone:407-631-4579
Mailing Address - Fax:
Practice Address - Street 1:13800 VETERANS WAY
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32827-7401
Practice Address - Country:US
Practice Address - Phone:407-631-4579
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-10
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS54946183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist