Provider Demographics
NPI:1720218506
Name:TARA PHARRMACY SE LLC
Entity Type:Organization
Organization Name:TARA PHARRMACY SE LLC
Other - Org Name:TARA PHARMACY SE LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:R
Authorized Official - Last Name:COX
Authorized Official - Suffix:II
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:601-664-1664
Mailing Address - Street 1:11643 LILBURN PARK RD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63146-3535
Mailing Address - Country:US
Mailing Address - Phone:314-567-7239
Mailing Address - Fax:314-995-8524
Practice Address - Street 1:11643 LILBURN PARK RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63146-3535
Practice Address - Country:US
Practice Address - Phone:314-567-7239
Practice Address - Fax:314-995-8524
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-15
Last Update Date:2022-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009019258333600000X
IL054.0184703336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2121154OtherPK
MO606430403Medicaid
MO20475756Medicaid