Provider Demographics
NPI:1568443489
Name:THERACOM
Entity Type:Organization
Organization Name:THERACOM
Other - Org Name:THERACOM
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSISTANT SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:ALICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:469-365-7030
Mailing Address - Street 1:9717 KEY WEST AVE
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20850-3982
Mailing Address - Country:US
Mailing Address - Phone:301-337-4200
Mailing Address - Fax:301-337-4135
Practice Address - Street 1:9717 KEY WEST AVE
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20850-3982
Practice Address - Country:US
Practice Address - Phone:301-337-4200
Practice Address - Fax:301-337-4135
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-08
Last Update Date:2017-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336M0002X
MDPO55973336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336S0011XSuppliersPharmacySpecialty Pharmacy
No333600000XSuppliersPharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2135654OtherPK