| Organization Name: | TIDEWATER PHARMACY INC |
| NPI Number: | 1003972373 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | LEO MALLARD (MNGR) |
| Mailing Address: | 28948 Three Notch Rd Mechanicsville |
| State: | MD US |
| Postal Code: | 206599998 |
| Phone Number: | 3018844646 |
| Fax Number: | 3018847329 |
| NPI Enumeration Date: | 12/29/2006 |
| NPI Last Update Date: | 12/24/2012 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 332B00000X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | N |
| State: | |
| Taxonomy Type: | Suppliers |
| Taxonomy Classification: | Durable Medical Equipment & Medical Supplies |
| Taxonomy Specialization: | |
| Taxonomy Definition: | A supplier of medical equipment such as respirators, wheelchairs, home dialysis systems, or monitoring systems, that are prescribed by a physician for a patient |