1609432459 NPI number — BRX LLC

Table of content: (NPI 1609432459)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609432459 NPI number — BRX LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRX LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
CHAMPION PHARMACY AND WELLNESS
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1609432459
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/25/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
38 LONE PINE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MASONTOWN
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
26542-8604
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
319 S VIRGINIA AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRIDGEPORT
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26330-1744
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-842-7979
Provider Business Practice Location Address Fax Number:
304-848-9797
Provider Enumeration Date:
05/17/2019

Additional Information

Authorized Official

Authorized Official Last Name:
BELLDINA
Authorized Official First Name:
ERIC
Authorized Official Middle Name:
B.
Authorized Official Title or Position:
MEMBER
Authorized Official Telephone Number:
304-276-5066

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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