1619167764 NPI number — THE WOUND STORE, LLC

Table of content: (NPI 1619167764)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619167764 NPI number — THE WOUND STORE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE WOUND STORE, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1619167764
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 30475
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MESA
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85275-0475
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
602-819-9434
Provider Business Mailing Address Fax Number:
866-453-0085

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10300 N SCOTTSDALE RD
Provider Second Line Business Practice Location Address:
SUITE 11/12
Provider Business Practice Location Address City Name:
SCOTTSDALE
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85253-1449
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
602-819-9434
Provider Business Practice Location Address Fax Number:
866-453-0085
Provider Enumeration Date:
07/25/2007

Additional Information

Authorized Official

Authorized Official Last Name:
KIEBORZ
Authorized Official First Name:
TIMOTHY
Authorized Official Middle Name:
JAMES
Authorized Official Title or Position:
CEO/OWNER
Authorized Official Telephone Number:
602-819-9434

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: Y004798 . This is a "STATE PHARMACY LICENSE" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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