Provider Demographics
NPI:1104198688
Name:OM TSM LLC
Entity Type:Organization
Organization Name:OM TSM LLC
Other - Org Name:DURBIN PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:OM
Authorized Official - Middle Name:
Authorized Official - Last Name:TSM
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:904-619-9000
Mailing Address - Street 1:14965 OLD SAINT AUGUSTINE RD UNIT 108
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32258-9481
Mailing Address - Country:US
Mailing Address - Phone:904-619-9000
Mailing Address - Fax:904-634-7458
Practice Address - Street 1:14965 OLD SAINT AUGUSTINE RD UNIT 108
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32258-9481
Practice Address - Country:US
Practice Address - Phone:904-619-9000
Practice Address - Fax:904-634-7458
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-31
Last Update Date:2016-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0003X
FLPH259213336C0003X, 3336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy
No333600000XSuppliersPharmacy
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2133655OtherPK
FL004947900Medicaid