Provider Demographics
NPI:1821292731
Name:TARA PHARMACY SE LLC
Entity Type:Organization
Organization Name:TARA PHARMACY SE LLC
Other - Org Name:
Other - Org Type:
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:PHARMD
Authorized Official - Phone:601-664-1664
Mailing Address - Street 1:P.O. BOX 428
Mailing Address - Street 2:3690 SOUTHWESTERN BLVD
Mailing Address - City:ORCHARD PARK
Mailing Address - State:NY
Mailing Address - Zip Code:14127-0428
Mailing Address - Country:US
Mailing Address - Phone:716-662-4955
Mailing Address - Fax:
Practice Address - Street 1:110 METROPLEX BLVD
Practice Address - Street 2:SUITE H
Practice Address - City:PEARL
Practice Address - State:MS
Practice Address - Zip Code:39208
Practice Address - Country:US
Practice Address - Phone:601-664-1664
Practice Address - Fax:601-664-1661
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-13
Last Update Date:2022-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01902360Medicaid