Provider Demographics
NPI:1508112392
Name:TARRYTOWN EXPOCARE, LLC
Entity Type:Organization
Organization Name:TARRYTOWN EXPOCARE, LLC
Other - Org Name:TARRYTOWN EXPOCARE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:D
Authorized Official - Last Name:NEWBERRY
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:512-617-7312
Mailing Address - Street 1:8500 SHOAL CREEK BLVD BLDG 1
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78757-6888
Mailing Address - Country:US
Mailing Address - Phone:512-617-7312
Mailing Address - Fax:512-617-7313
Practice Address - Street 1:8500 SHOAL CREEK BLVD BLDG 1
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78757-6888
Practice Address - Country:US
Practice Address - Phone:512-617-7312
Practice Address - Fax:512-617-7313
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-30
Last Update Date:2020-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX281503336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2137179OtherPK
TX351075Medicaid
TX146679Medicaid