Provider Demographics
NPI:1003872904
Name:TAMARACK LTD
Entity Type:Organization
Organization Name:TAMARACK LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:H
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:304-255-6500
Mailing Address - Street 1:PO BOX 1102
Mailing Address - Street 2:
Mailing Address - City:BECKLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25802-1102
Mailing Address - Country:US
Mailing Address - Phone:304-255-6500
Mailing Address - Fax:304-253-5420
Practice Address - Street 1:386 RAGLAND RD
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-9722
Practice Address - Country:US
Practice Address - Phone:304-255-6500
Practice Address - Fax:304-253-5420
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-21
Last Update Date:2012-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0148499000Medicaid
WV0148499000Medicaid