1326059965 NPI number — EXPRESS MEDS RX LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326059965 NPI number — EXPRESS MEDS RX LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EXPRESS MEDS RX 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:
1326059965
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/16/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 9830
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SALT LAKE CITY
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84109-9830
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-716-4721
Provider Business Mailing Address Fax Number:
801-716-4872

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1860 BOY SCOUT DR
Provider Second Line Business Practice Location Address:
STE 201
Provider Business Practice Location Address City Name:
FORT MYERS
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33907-2144
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
239-274-3269
Provider Business Practice Location Address Fax Number:
239-936-1761
Provider Enumeration Date:
08/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
LUACES
Authorized Official First Name:
RICARDO
Authorized Official Middle Name:
Authorized Official Title or Position:
VP
Authorized Official Telephone Number:
239-936-1041

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  PH22069 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 31346700 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1019834 . This is a "NCPDP PROVIDER IDENTIFICATION NUMBER" identifier . This identifiers is of the category "OTHER".




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