Provider Demographics
NPI:1851590210
Name:TDS INC
Entity Type:Organization
Organization Name:TDS INC
Other - Org Name:CRYSTAL FALLS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:ROELL
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:906-774-1044
Mailing Address - Street 1:PO BOX 189
Mailing Address - Street 2:
Mailing Address - City:IRON MOUNTAIN
Mailing Address - State:MI
Mailing Address - Zip Code:49801-0189
Mailing Address - Country:US
Mailing Address - Phone:906-774-2841
Mailing Address - Fax:906-774-3015
Practice Address - Street 1:1363 US HIGHWAY 2
Practice Address - Street 2:
Practice Address - City:CRYSTAL FALLS
Practice Address - State:MI
Practice Address - Zip Code:49920-1089
Practice Address - Country:US
Practice Address - Phone:906-875-3601
Practice Address - Fax:906-875-3604
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-16
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
MI53010086703336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI36222700Medicaid
MI2370132Medicaid
2042750OtherPK
MI2370132Medicaid