Provider Demographics
NPI:1619167764
Name:THE WOUND STORE, LLC
Entity Type:Organization
Organization Name:THE WOUND STORE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:KIEBORZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:602-819-9434
Mailing Address - Street 1:PO BOX 30475
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85275-0475
Mailing Address - Country:US
Mailing Address - Phone:602-819-9434
Mailing Address - Fax:866-453-0085
Practice Address - Street 1:10300 N SCOTTSDALE RD
Practice Address - Street 2:SUITE 11/12
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85253-1449
Practice Address - Country:US
Practice Address - Phone:602-819-9434
Practice Address - Fax:866-453-0085
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-25
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZY004798OtherSTATE PHARMACY LICENSE
AZFT0321795OtherDEA
AZY004798OtherSTATE PHARMACY LICENSE