Provider Demographics
NPI: | 1669016895 |
---|---|
Name: | TRINITY HEALTH PHARMACY SERVICES, LLC |
Entity Type: | Organization |
Organization Name: | TRINITY HEALTH PHARMACY SERVICES, LLC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | VP AND CHIEF PHARMACY OFFICER |
Authorized Official - Prefix: | |
Authorized Official - First Name: | DAMON |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | REDDING |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | PHARMD, MBA |
Authorized Official - Phone: | 734-343-7600 |
Mailing Address - Street 1: | 12279 BLUFFTON ROAD |
Mailing Address - Street 2: | |
Mailing Address - City: | FORT WAYNE |
Mailing Address - State: | IN |
Mailing Address - Zip Code: | 46809 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 734-343-7600 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 12279 BLUFFTON ROAD |
Practice Address - Street 2: | |
Practice Address - City: | FORT WAYNE |
Practice Address - State: | IN |
Practice Address - Zip Code: | 46809 |
Practice Address - Country: | US |
Practice Address - Phone: | 407-697-4277 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2019-10-31 |
Last Update Date: | 2022-04-25 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 3336S0011X | Suppliers | Pharmacy | Specialty Pharmacy |
No | 332B00000X | Suppliers | Durable Medical Equipment & Medical Supplies | |
No | 333600000X | Suppliers | Pharmacy | |
No | 3336C0003X | Suppliers | Pharmacy | Community/Retail Pharmacy |
No | 3336M0002X | Suppliers | Pharmacy | Mail Order Pharmacy |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
OH | 0391994 | Medicaid | |
WI | 2521-43 | Other | PHARMACY LICENSE |
HI | PMP-1895 | Other | PHARMACY LICENSE |
MD | PO8489 | Other | PHARMACY LICENSE |
ND | PHAR1918 | Other | PHARMACY LICENSE |
IN | 300033160 | Medicaid | |
MI | VS0172399 | Medicaid | |
IL | 054.021498 | Other | PHARMACY LICENSE |
UT | 12766690-1708 | Other | PHARMACY LICENSE |
DE | A9-0012676 | Other | PHARMACY LICENSE |
KY | IN2605 | Other | PHARMACY LICENSE |
MT | PHA-MOP-LIC-84404 | Other | PHARMACY LICENSE |
OR | RP-0003705 | Other | PHARMACY LICENSE |
NC | 14929 | Other | PHARMACY LICENSE |
MN | 266265 | Other | PHARMACY LICENSE |
ME | MO40003141 | Other | PHARMACY LICENSE |
WY | NR-51935 | Other | PHARMACY LICENSE |
IA | NR5450 | Other | PHARMACY LICENSE |
CT | 008107334 | Medicaid | |
VT | 036.0134601 | Other | PHARMACY LICENSE |
NY | 038275 | Other | PHARMACY LICENSE |
PA | 103759236 | Medicaid | |
SD | 400-2266 | Other | PHARMACY LICENSE |
ID | 58582MS | Other | PHARMACY LICENSE |
NH | NR2270 | Other | PHARMACY LICENSE |
CO | OSP.0007488 | Other | PHARMACY LICENSE |
CT | PCN.0003825 | Other | PHARMACY LICENSE |
PA | NP001573 | Other | PHARMACY LICENSE |
NM | PH0005403 | Other | PHARMACY LICENSE |
FL | PH33336 | Other | PHARMACY LICENSE |
AZ | Y008405 | Other | PHARMACY LICENSE |
AK | 193819 | Other | PHARMACY LICENSE |
NJ | 28RO00224700 | Other | PHARMACY LICENSE |
WV | MO0561538 | Other | PHARMACY LICENSE |
VA | 0214002479 | Other | PHARMACY LICENSE |
OH | 0240000154 | Other | PHARMACY LICENSE |
MO | 2021001793 | Other | PHARMACY LICENSE |
ID | 202190019 | Medicaid | |
MI | 5301012447 | Other | PHARMACY LICENSE |
IN | 60006758A | Other | PHARMACY LICENSE |
GA | PHNR001945 | Other | PHARMACY LICENSE |