Provider Demographics
NPI:1063782399
Name:TIDWELL, MYKEL LINN (PHARMD)
Entity type:Individual
Prefix:DR
First Name:MYKEL
Middle Name:LINN
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 1:66 LAKE TERRY DR
Mailing Address - Street 2:
Mailing Address - City:MAYFIELD
Mailing Address - State:KY
Mailing Address - Zip Code:42066-6982
Mailing Address - Country:US
Mailing Address - Phone:270-705-1141
Mailing Address - Fax:
Practice Address - Street 1:1520 CUBA RD
Practice Address - Street 2:
Practice Address - City:MAYFIELD
Practice Address - State:KY
Practice Address - Zip Code:42066-6809
Practice Address - Country:US
Practice Address - Phone:270-705-1141
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-04
Last Update Date:2024-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY015489183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist