1699223578 NPI number — IMGRX EAST, LLC

Table of content: (NPI 1699223578)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699223578 NPI number — IMGRX EAST, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
IMGRX EAST, 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:
SOUTHWEST VIRGINIA COMMUNITY PHARMACY
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:
1699223578
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/01/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1999 HARRISON ST STE 1530
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OAKLAND
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94612-4730
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
510-770-6343
Provider Business Mailing Address Fax Number:
512-233-5828

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2195 EUCLID AVE STE 6
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRISTOL
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24201-3655
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
512-596-2930
Provider Business Practice Location Address Fax Number:
760-859-3614
Provider Enumeration Date:
09/20/2016

Additional Information

Authorized Official

Authorized Official Last Name:
REW
Authorized Official First Name:
KEVIN
Authorized Official Middle Name:
Authorized Official Title or Position:
GENERAL COUNSEL & COO
Authorized Official Telephone Number:
510-770-6343

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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