Provider Demographics
NPI:1811281181
Name:TIDWELL, KRISTOPHER RICHARD (PHARMD)
Entity type:Individual
Prefix:DR
First Name:KRISTOPHER
Middle Name:RICHARD
Last Name:TIDWELL
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1106 N COLUMBIA CENTER BLVD
Mailing Address - Street 2:TARGET PHARMACY - T0830
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99336-1161
Mailing Address - Country:US
Mailing Address - Phone:509-737-1700
Mailing Address - Fax:509-378-3653
Practice Address - Street 1:1106 N COLUMBIA CENTER BLVD
Practice Address - Street 2:TARGET PHARMACY - T0830
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336-1161
Practice Address - Country:US
Practice Address - Phone:509-737-1700
Practice Address - Fax:509-378-3653
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-04
Last Update Date:2012-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH 60173826183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist