Provider Demographics
NPI:1194977504
Name:TJD ENTERPRISES, LLC
Entity type:Organization
Organization Name:TJD ENTERPRISES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:A
Authorized Official - Last Name:DOEHRING
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:618-327-3214
Mailing Address - Street 1:143 S WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62263-1430
Mailing Address - Country:US
Mailing Address - Phone:618-327-3214
Mailing Address - Fax:618-327-9786
Practice Address - Street 1:143 S WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:IL
Practice Address - Zip Code:62263-1430
Practice Address - Country:US
Practice Address - Phone:618-427-3214
Practice Address - Fax:618-327-9786
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-16
Last Update Date:2012-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0540081483336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0682490001Medicare NSC