Basic Information
| Provider Information | |||||||||
| NPI: | 1821292731 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TARA PHARMACY SE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 428 | ||||||||
| Address2: | 3690 SOUTHWESTERN BLVD | ||||||||
| City: | ORCHARD PARK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 141270428 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166624955 | ||||||||
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| Practice Location | |||||||||
| Address1: | 110 METROPLEX BLVD | ||||||||
| Address2: | SUITE H | ||||||||
| City: | PEARL | ||||||||
| State: | MS | ||||||||
| PostalCode: | 39208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6016641664 | ||||||||
| FaxNumber: | 6016641661 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2007 | ||||||||
| LastUpdateDate: | 02/25/2022 | ||||||||
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| AuthorizedOfficialLastName: | COX | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | R. | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6016641664 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | II | ||||||||
| AuthorizedOfficialCredential: | PHARMD | ||||||||
| NPICertificationDate: | 02/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336L0003X | Y | Suppliers | Pharmacy | Long Term Care Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 01902360 | 05 | MS | MEDICAID |