Provider Demographics
NPI:1023302643
Name:TRI-STATE MEDICAL SPECIALISTS LLC
Entity type:Organization
Organization Name:TRI-STATE MEDICAL SPECIALISTS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOANN
Authorized Official - Middle Name:
Authorized Official - Last Name:VENGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-788-3333
Mailing Address - Street 1:PO BOX 10966
Mailing Address - Street 2:
Mailing Address - City:FORT MOHAVE
Mailing Address - State:AZ
Mailing Address - Zip Code:86427-0966
Mailing Address - Country:US
Mailing Address - Phone:928-788-3333
Mailing Address - Fax:928-788-3555
Practice Address - Street 1:1510 WAGON WHEEL LANE
Practice Address - Street 2:SUITE 110
Practice Address - City:FORT MOHAVE
Practice Address - State:AZ
Practice Address - Zip Code:86426-6698
Practice Address - Country:US
Practice Address - Phone:928-788-3333
Practice Address - Fax:928-788-3555
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TRI-STATE MEDICAL SPECIALISTS LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-05-31
Last Update Date:2022-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site