Provider Demographics
NPI:1811974488
Name:TDS INC
Entity type:Organization
Organization Name:TDS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:ROELL
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:906-774-1044
Mailing Address - Street 1:PO BOX 189
Mailing Address - Street 2:
Mailing Address - City:IRON MOUNTAIN
Mailing Address - State:MI
Mailing Address - Zip Code:49801-0189
Mailing Address - Country:US
Mailing Address - Phone:906-774-2841
Mailing Address - Fax:906-774-3015
Practice Address - Street 1:1112 S STEPHENSON AVE
Practice Address - Street 2:
Practice Address - City:IRON MOUNTAIN
Practice Address - State:MI
Practice Address - Zip Code:49801-4038
Practice Address - Country:US
Practice Address - Phone:906-774-3654
Practice Address - Fax:906-774-5502
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-27
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5301002759332B00000X
333600000X, 3336C0003X, 3336L0003X, 3336S0011X
WI1815-433336C0004X
FLPH305153336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2040090OtherPK
MI2305781Medicaid
WI33126100Medicaid
MI2305781Medicaid
2040090OtherPK