Provider Demographics
NPI:1821379587
Name:TD HEALTHCARE LLC
Entity Type:Organization
Organization Name:TD HEALTHCARE LLC
Other - Org Name:DENVER CITY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/MANAGING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:FUNG
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:813-244-9882
Mailing Address - Street 1:105 E BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:DENVER CITY
Mailing Address - State:TX
Mailing Address - Zip Code:79323-3225
Mailing Address - Country:US
Mailing Address - Phone:806-592-3333
Mailing Address - Fax:806-592-3633
Practice Address - Street 1:105 E BROADWAY ST
Practice Address - Street 2:
Practice Address - City:DENVER CITY
Practice Address - State:TX
Practice Address - Zip Code:79323-3225
Practice Address - Country:US
Practice Address - Phone:806-592-3333
Practice Address - Fax:806-592-3633
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-07
Last Update Date:2017-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X, 3336S0011X
TX276333336C0003X, 333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2131862OtherPK
TX148297Medicaid
TX146454Medicaid