Provider Demographics
NPI:1942384078
Name:TARRYTOWN PHARMACY LLC
Entity Type:Organization
Organization Name:TARRYTOWN PHARMACY LLC
Other - Org Name:TARRYTOWN PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:NEWBERRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-478-6419
Mailing Address - Street 1:2727 EXPOSITION BLVD
Mailing Address - Street 2:STE 105
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78703-1228
Mailing Address - Country:US
Mailing Address - Phone:512-478-6419
Mailing Address - Fax:512-478-1638
Practice Address - Street 1:2727 EXPOSITION BLVD
Practice Address - Street 2:STE 105
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78703-1228
Practice Address - Country:US
Practice Address - Phone:512-478-6419
Practice Address - Fax:512-478-1638
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2022-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
163WD0400X, 183500000X, 1835P0018X, 261QP2300X, 333600000X, 3336L0003X
TX18123336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No163WD0400XNursing Service ProvidersRegistered NurseDiabetes EducatorGroup - Multi-Specialty
No183500000XPharmacy Service ProvidersPharmacistGroup - Multi-Specialty
No1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy SpecialistGroup - Multi-Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX110162Medicaid
2093490OtherPK
2093490OtherPK