Provider Demographics
NPI:1871587642
Name:TJT PHARMACY, INC
Entity type:Organization
Organization Name:TJT PHARMACY, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:TUFTY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-589-2233
Mailing Address - Street 1:1016 4TH ST
Mailing Address - Street 2:
Mailing Address - City:FULTON
Mailing Address - State:IL
Mailing Address - Zip Code:61252-1716
Mailing Address - Country:US
Mailing Address - Phone:815-589-2233
Mailing Address - Fax:815-589-4789
Practice Address - Street 1:1016 4TH ST
Practice Address - Street 2:
Practice Address - City:FULTON
Practice Address - State:IL
Practice Address - Zip Code:61252-1716
Practice Address - Country:US
Practice Address - Phone:815-589-2233
Practice Address - Fax:815-589-4789
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-07
Last Update Date:2007-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL212195OtherMEDICARE LEGACY NUMBER
IL212195OtherMEDICARE LEGACY NUMBER