=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992781553
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TURQUOISE, LTD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/15/2005
-----------------------------------------------------
Last Update Date | 07/06/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 955 S 2ND ST
-----------------------------------------------------
City | RATON
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87740-2301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-445-3131
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2407
-----------------------------------------------------
City | SHERMAN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75091-2407
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-893-0677
-----------------------------------------------------
Fax | 903-893-3639
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO
-----------------------------------------------------
Name | JOHN STOGNER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 903-893-0677
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number | PH2393
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number | PH2393
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 3336C0004X
-----------------------------------------------------
Taxonomy Name | Compounding Pharmacy
-----------------------------------------------------
License Number | PH2393
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | PH2393
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------