Provider Demographics
NPI:1184728131
Name:TRI-STATE RX LLC
Entity type:Organization
Organization Name:TRI-STATE RX LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:NATION
Authorized Official - Suffix:
Authorized Official - Credentials:RPH BS
Authorized Official - Phone:270-684-5398
Mailing Address - Street 1:3030 BURLEW BLVD
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42303-6486
Mailing Address - Country:US
Mailing Address - Phone:270-684-5398
Mailing Address - Fax:270-683-8373
Practice Address - Street 1:4849 POLLACK AVE
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47715-5750
Practice Address - Country:US
Practice Address - Phone:812-962-4664
Practice Address - Fax:812-962-4660
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-12
Last Update Date:2017-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
IN60005757A3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2024675OtherPK
IN200455200Medicaid
4958220001Medicare NSC