1093014573 NPI number — MED EX DIRECT, LLC

Table of content: (NPI 1093014573)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093014573 NPI number — MED EX DIRECT, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MED EX DIRECT, 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:
Provider Other Organization Name Type Code:
6
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:
1093014573
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13201 STEPHENS RD
Provider Second Line Business Mailing Address:
SUITE D
Provider Business Mailing Address City Name:
WARREN
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48089-4340
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
877-881-3100
Provider Business Mailing Address Fax Number:
877-899-6360

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13201 STEPHENS RD
Provider Second Line Business Practice Location Address:
SUITE D
Provider Business Practice Location Address City Name:
WARREN
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48089-4340
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
877-881-3100
Provider Business Practice Location Address Fax Number:
877-899-6360
Provider Enumeration Date:
03/23/2011

Additional Information

Authorized Official

Authorized Official Last Name:
GALLANT
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
877-881-3100

Provider Taxonomy Codes

  • Taxonomy code: 3336C0004X , with the licence number:  5301009263 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 5301009263 . This is a "STATE PHARMACY LICENSE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 5315043773 . This is a "STATE PHARMACY CONTROL LICENSE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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