Provider Demographics
NPI:1558350769
Name:TISDALE, ROBERT C (RPH)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:C
Last Name:TISDALE
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 1:2610 NORTHWIND DR
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23233-3313
Mailing Address - Country:US
Mailing Address - Phone:804-360-4019
Mailing Address - Fax:
Practice Address - Street 1:5700 BROOK RD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23227-2257
Practice Address - Country:US
Practice Address - Phone:804-264-1597
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202004217183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist