Provider Demographics
NPI:1952558686
Name:TRI STATE RX, LLC
Entity Type:Organization
Organization Name:TRI STATE RX, LLC
Other - Org Name:NATION'S MEDICINES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:HAYWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:812-962-4664
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:270-685-4931
Mailing Address - Fax:270-685-5742
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:2008-08-25
Last Update Date:2008-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN200460670A332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200460670AMedicaid