Healthcare Provider Details

I. General information

NPI: 1699030288
Provider Name (Legal Business Name): TMB CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2012
Last Update Date: 02/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

235 W FLETCHER ST
HAXTUN CO
80731-2737
US

IV. Provider business mailing address

235 W FLETCHER ST
HAXTUN CO
80731-2737
US

V. Phone/Fax

Practice location:
  • Phone: 970-774-3784
  • Fax: 970-774-3785
Mailing address:
  • Phone: 970-474-3411
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number1680000002
License Number StateCO

VIII. Authorized Official

Name: MELISSA BUMGARDNER
Title or Position: OWNER/PRESIDENT/PHARMACIST
Credential:
Phone: 970-474-3672