Provider Demographics
NPI:1316255136
Name:TISDELL, JAMES NICHOLAS (PHARMD)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:NICHOLAS
Last Name:TISDELL
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 1:3501 CHAMPION LAKE BLVD
Mailing Address - Street 2:APT. 1609
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-3772
Mailing Address - Country:US
Mailing Address - Phone:318-564-1057
Mailing Address - Fax:
Practice Address - Street 1:3555 GREENWOOD RD
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71109-5209
Practice Address - Country:US
Practice Address - Phone:318-525-0144
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-14
Last Update Date:2010-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPST019166183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist