Provider Demographics
NPI:1750327847
Name:TERRITORIAL DRUG CO INC
Entity Type:Organization
Organization Name:TERRITORIAL DRUG CO INC
Other - Org Name:TOMBSTONE HEALTHMART PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:
Authorized Official - Last Name:ROETHER
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:520-457-3543
Mailing Address - Street 1:PO BOX 1279
Mailing Address - Street 2:
Mailing Address - City:TOMBSTONE
Mailing Address - State:AZ
Mailing Address - Zip Code:85638-1279
Mailing Address - Country:US
Mailing Address - Phone:520-457-3543
Mailing Address - Fax:520-457-3187
Practice Address - Street 1:524 E ALLEN STREET
Practice Address - Street 2:
Practice Address - City:TOMBSTONE
Practice Address - State:AZ
Practice Address - Zip Code:85638
Practice Address - Country:US
Practice Address - Phone:520-457-3543
Practice Address - Fax:520-457-3187
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-20
Last Update Date:2013-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZY0055083336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1989821OtherPK
AZ325838Medicaid
1989821OtherPK