MEDICARE: THEO WHOLESALE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QR1100X	Research Clinic/Center

General Provider Information

NPI Number	:	1457210825
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THEO WHOLESALE LLC

Provider Business Mailing Address
First Line	:	30 N GOULD ST STE N
Second Line	:
City	:	SHERIDAN
State	:	WY
Zip	:	82801-6317
Country	:	US
Telephone Number	:	208-892-9780
Fax Number	:

Provider Business Practice Location Address
First Line	:	30 N GOULD ST STE N
Second Line	:
City	:	SHERIDAN
State	:	WY
Zip	:	82801-6317
Country	:	US
Telephone Number	:	208-892-9780
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MS. THEODORE DENNIS BECKER
Credential	:	N/A
Telephone Number	:	208-892-9780

Provider Enumeration Date	:	01/20/2026
Last Update Date	:	01/20/2026

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Directions to “THEO WHOLESALE LLC ” Practice Location

Language	Start Address	Practice Location

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