Provider Demographics
NPI:1356459598
Name:TEDESCO, TIFFANY LISA (RPH)
Entity type:Individual
Prefix:MRS
First Name:TIFFANY
Middle Name:LISA
Last Name:TEDESCO
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8967 NW BEAVER DR
Mailing Address - Street 2:
Mailing Address - City:JOHNSTON
Mailing Address - State:IA
Mailing Address - Zip Code:50131-1906
Mailing Address - Country:US
Mailing Address - Phone:515-253-2652
Mailing Address - Fax:
Practice Address - Street 1:1801 HICKMAN RD
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50314-1548
Practice Address - Country:US
Practice Address - Phone:515-282-2470
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA18775183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist