Provider Demographics
NPI:1013319714
Name:TIDWELL, CROCKETT (RPH)
Entity Type:Individual
Prefix:MR
First Name:CROCKETT
Middle Name:
Last Name:TIDWELL
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 1:4205 98TH ST
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79423-3971
Mailing Address - Country:US
Mailing Address - Phone:806-798-6115
Mailing Address - Fax:806-798-6117
Practice Address - Street 1:4205 98TH ST
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79423-3971
Practice Address - Country:US
Practice Address - Phone:806-798-6115
Practice Address - Fax:806-798-6117
Is Sole Proprietor?:No
Enumeration Date:2014-09-24
Last Update Date:2014-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX384481835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX38448OtherPHARMACY LICENSE