Healthcare Provider Details

I. General information

NPI: 1154308625
Provider Name (Legal Business Name): TRI STATE PHARMACEUTICAL SERVICES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/27/2005
Last Update Date: 01/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4119 W MAIN ST
DOTHAN AL
36305-1023
US

IV. Provider business mailing address

4119 W MAIN ST
DOTHAN AL
36305-1023
US

V. Phone/Fax

Practice location:
  • Phone: 334-793-1316
  • Fax: 334-793-4920
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number111313
License Number StateAL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier0116839
Identifier TypeOTHER
Identifier State
Identifier IssuerNCPDP PROVIDER IDENTIFICATION NUMBER
# 2
Identifier051555957
Identifier TypeOTHER
Identifier StateAL
Identifier IssuerMEDICARE CAHABA GBA-AL PART B
# 3
Identifier100003015
Identifier TypeMEDICAID
Identifier StateAL
Identifier Issuer

VIII. Authorized Official

Name: MICHAEL STRINGER
Title or Position: VP
Credential: RPH
Phone: 334-793-1316