Provider Demographics
NPI:1033155494
Name:MEDI STAT RX LLC
Entity Type:Organization
Organization Name:MEDI STAT RX LLC
Other - Org Name:MEDI STAT RX
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JANAK
Authorized Official - Middle Name:
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-247-9101
Mailing Address - Street 1:500 W JEFFERSON BLVD
Mailing Address - Street 2:STE A
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75208-4722
Mailing Address - Country:US
Mailing Address - Phone:214-946-3822
Mailing Address - Fax:214-946-8300
Practice Address - Street 1:500 W JEFFERSON BLVD
Practice Address - Street 2:STE A
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75208-4722
Practice Address - Country:US
Practice Address - Phone:214-946-3822
Practice Address - Fax:214-946-8300
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-22
Last Update Date:2010-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336M0002X
TX232383336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX145477Medicaid
4535588OtherNCPDP PROVIDER IDENTIFICATION NUMBER
5151310001Medicare NSC