Provider Demographics
NPI:1679655476
Name:TIBBOTTS PHARMACY INC
Entity type:Organization
Organization Name:TIBBOTTS PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROWLAND
Authorized Official - Middle Name:
Authorized Official - Last Name:TIBBOTT
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:814-472-9390
Mailing Address - Street 1:1104 W HIGH ST
Mailing Address - Street 2:BOX 179
Mailing Address - City:EBENSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:15931-1707
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1104 W HIGH ST
Practice Address - Street 2:STE1, KIMBALL PLAZA
Practice Address - City:EBENSBURG
Practice Address - State:PA
Practice Address - Zip Code:15931-1707
Practice Address - Country:US
Practice Address - Phone:814-472-9390
Practice Address - Fax:814-472-1166
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2011-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPP412694L3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA000933360Medicaid
3911636OtherNCPDP PROVIDER IDENTIFICATION NUMBER