1992958854 NPI number — EXPRESSWAY PHARMACY 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 1992958854 NPI number — EXPRESSWAY PHARMACY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EXPRESSWAY PHARMACY 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:
1992958854
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/07/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
702 E EXPRESSWAY 83
Provider Second Line Business Mailing Address:
STE A1
Provider Business Mailing Address City Name:
DONNA
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78537-2741
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
956-464-7600
Provider Business Mailing Address Fax Number:
956-464-7601

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
702 E EXPRESSWAY 83
Provider Second Line Business Practice Location Address:
STE A1
Provider Business Practice Location Address City Name:
DONNA
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78537-2741
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
956-464-7600
Provider Business Practice Location Address Fax Number:
956-464-7601
Provider Enumeration Date:
10/23/2008

Additional Information

Authorized Official

Authorized Official Last Name:
TREVINO
Authorized Official First Name:
MARIO
Authorized Official Middle Name:
Authorized Official Title or Position:
PIC
Authorized Official Telephone Number:
956-464-7600

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  26226 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 4550302 . This is a "NCPDP PROVIDER IDENTIFICATION NUMBER" identifier . This identifiers is of the category "OTHER".




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