Provider Demographics
NPI:1134490840
Name:TRICARE PHARMACY LLC
Entity Type:Organization
Organization Name:TRICARE PHARMACY LLC
Other - Org Name:TONNA PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:FOUNDER/CEO
Authorized Official - Prefix:
Authorized Official - First Name:GLORIA
Authorized Official - Middle Name:
Authorized Official - Last Name:MBONU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:281-953-0030
Mailing Address - Street 1:PO BOX 113
Mailing Address - Street 2:
Mailing Address - City:ALIEF
Mailing Address - State:TX
Mailing Address - Zip Code:77411-0113
Mailing Address - Country:US
Mailing Address - Phone:281-953-0030
Mailing Address - Fax:281-953-0028
Practice Address - Street 1:5225 KATY FWY STE 101A
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77007-2292
Practice Address - Country:US
Practice Address - Phone:281-953-0030
Practice Address - Fax:281-953-0028
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-26
Last Update Date:2016-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
TX279733336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2134592OtherPK