Healthcare Provider Details

I. General information

NPI: 1265695852
Provider Name (Legal Business Name): THERACOM LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/03/2008
Last Update Date: 07/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9717 KEY WEST AVE
ROCKVILLE MD
20850-3982
US

IV. Provider business mailing address

PO BOX 840688
DALLAS TX
75284-0688
US

V. Phone/Fax

Practice location:
  • Phone: 301-337-4200
  • Fax: 301-337-4135
Mailing address:
  • Phone: 800-225-5967
  • Fax: 909-799-4364

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336M0002X
TaxonomyMail Order Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MS. SANDY L. CAMPA
Title or Position: PROVIDERSHIP SUPERVISOR
Credential:
Phone: 800-225-5967