Provider Demographics
NPI:1699030288
Name:TMB CORPORATION
Entity type:Organization
Organization Name:TMB CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT/PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:BUMGARDNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-474-3672
Mailing Address - Street 1:235 W FLETCHER ST
Mailing Address - Street 2:
Mailing Address - City:HAXTUN
Mailing Address - State:CO
Mailing Address - Zip Code:80731-2737
Mailing Address - Country:US
Mailing Address - Phone:970-474-3411
Mailing Address - Fax:
Practice Address - Street 1:235 W FLETCHER ST
Practice Address - Street 2:
Practice Address - City:HAXTUN
Practice Address - State:CO
Practice Address - Zip Code:80731-2737
Practice Address - Country:US
Practice Address - Phone:970-774-3784
Practice Address - Fax:970-774-3785
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-10
Last Update Date:2013-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO16800000023336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO44108877Medicaid
0622654OtherNCPDP PROVIDER IDENTIFICATION NUMBER