Provider Demographics
NPI:1518553833
Name:TACKAGE, TODD A
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:A
Last Name:TACKAGE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4940 COTTONVILLE RD
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:45335-1522
Mailing Address - Country:US
Mailing Address - Phone:937-675-6500
Mailing Address - Fax:937-675-6540
Practice Address - Street 1:4940 COTTONVILLE RD
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:OH
Practice Address - Zip Code:45335-1522
Practice Address - Country:US
Practice Address - Phone:937-675-6500
Practice Address - Fax:937-675-6540
Is Sole Proprietor?:No
Enumeration Date:2020-12-21
Last Update Date:2020-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03322204183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist