Provider Demographics
NPI:1518479773
Name:TNT APOTHECARY LLC
Entity Type:Organization
Organization Name:TNT APOTHECARY LLC
Other - Org Name:HAGERMAN VALLEY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:GILL
Authorized Official - Last Name:WADSWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-786-6211
Mailing Address - Street 1:PO BOX 487
Mailing Address - Street 2:
Mailing Address - City:WENDELL
Mailing Address - State:ID
Mailing Address - Zip Code:83355-0487
Mailing Address - Country:US
Mailing Address - Phone:208-965-9012
Mailing Address - Fax:
Practice Address - Street 1:631 FROGS LNDG
Practice Address - Street 2:
Practice Address - City:HAGERMAN
Practice Address - State:ID
Practice Address - Zip Code:83332-5034
Practice Address - Country:US
Practice Address - Phone:208-536-5761
Practice Address - Fax:208-536-5852
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TNT APOTHECARY, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-10-27
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy