Organization
FULLER SELLE LLC
Active
Other names
TRILLIUM SPECIALTY HOSPITAL EAST VALLEY
Organization subpart
No
Provider details
NPI number
Authorized official
GARY ALEXANDER (CFO)
(210) 745-4000
Entity
Organization
Contact information
Practice address
215 S POWER RD, MESA, AZ 85206-5235
(408) 985-6992
Mailing address
777 E SONTERRA BLVD, STE 300, SAN ANTONIO, TX 78258-4246
Taxonomy
Speciality
Code
Description
License number
State
3336C0004X
Compounding Pharmacy
—
—
3336I0012X
Institutional Pharmacy
—
—
3336L0003X
Long Term Care Pharmacy
Primary
Y004869
AZ
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0355392
OTHER ID NUMBER
—
Enumeration date
06/30/2008
Last updated
06/30/2008
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