Provider Demographics
NPI:1548370497
Name:TAILSTORM HEALTH LLC
Entity type:Organization
Organization Name:TAILSTORM HEALTH LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:HARTLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-896-0454
Mailing Address - Street 1:15600 N BLACK CANYON HWY
Mailing Address - Street 2:STE B135
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85053-4055
Mailing Address - Country:US
Mailing Address - Phone:602-896-0454
Mailing Address - Fax:602-896-0456
Practice Address - Street 1:15600 N BLACK CANYON HWY
Practice Address - Street 2:STE B135
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85053-4055
Practice Address - Country:US
Practice Address - Phone:602-896-0454
Practice Address - Fax:602-896-0456
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2016-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
AZY0063113336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2151503OtherPK
AZ410717Medicaid