Provider Demographics
NPI:1770644429
Name:TIDMARSH, CHARLES BLAIR (RPH)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:BLAIR
Last Name:TIDMARSH
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 1:104 CHANTEMAR
Mailing Address - Street 2:
Mailing Address - City:SIMPSONVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29681-5101
Mailing Address - Country:US
Mailing Address - Phone:864-458-8699
Mailing Address - Fax:864-288-5608
Practice Address - Street 1:505 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MAULDIN
Practice Address - State:SC
Practice Address - Zip Code:29662-2345
Practice Address - Country:US
Practice Address - Phone:864-288-2600
Practice Address - Fax:864-288-5608
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC004079183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist