Provider Demographics
NPI:1003994518
Name:ADVANT-EDGE PHARMACY, INC
Entity Type:Organization
Organization Name:ADVANT-EDGE PHARMACY, INC
Other - Org Name:ADVANT EDGE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:EUSTACIO
Authorized Official - Middle Name:
Authorized Official - Last Name:RIVAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:915-595-0409
Mailing Address - Street 1:1576 LOMALAND DR
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79935-4202
Mailing Address - Country:US
Mailing Address - Phone:915-595-0409
Mailing Address - Fax:915-595-1028
Practice Address - Street 1:1576 LOMALAND DR
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79935-4202
Practice Address - Country:US
Practice Address - Phone:915-595-0409
Practice Address - Fax:915-595-1028
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336H0001X, 3336L0003X
TX193783336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2091866OtherPK
TX144844Medicaid