Provider Demographics
NPI:1073931887
Name:THEO PHARMACEUTICALS INC
Entity Type:Organization
Organization Name:THEO PHARMACEUTICALS INC
Other - Org Name:THEO PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RAKESH
Authorized Official - Middle Name:
Authorized Official - Last Name:TAMMABATTULA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:347-515-6789
Mailing Address - Street 1:13701 BEACH BLVD STE A2
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:CA
Mailing Address - Zip Code:92683-3201
Mailing Address - Country:US
Mailing Address - Phone:714-373-0214
Mailing Address - Fax:714-373-0839
Practice Address - Street 1:13701 BEACH BLVD
Practice Address - Street 2:STE A2
Practice Address - City:WESTMINSTER
Practice Address - State:CA
Practice Address - Zip Code:92683-3201
Practice Address - Country:US
Practice Address - Phone:714-373-0214
Practice Address - Fax:714-373-0839
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-31
Last Update Date:2017-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN265225333600000X
PANP0007943336C0003X
OHNRP.022668450-033336C0003X
CAPHY539003336C0003X
NVPH036783336C0003X
FLPH304903336M0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA8968740Medicaid
2162079OtherPK