Provider Demographics
NPI:1093014573
Name:MED EX DIRECT, LLC
Entity Type:Organization
Organization Name:MED EX DIRECT, LLC
Other - Org Name:M D COMPOUNDING SOLUTIONS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:GALLANT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:877-881-3100
Mailing Address - Street 1:13201 STEPHENS RD
Mailing Address - Street 2:SUITE D
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48089-4340
Mailing Address - Country:US
Mailing Address - Phone:877-881-3100
Mailing Address - Fax:877-899-6360
Practice Address - Street 1:13201 STEPHENS RD
Practice Address - Street 2:SUITE D
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48089-4340
Practice Address - Country:US
Practice Address - Phone:877-881-3100
Practice Address - Fax:877-899-6360
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-23
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010092633336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5301009263OtherSTATE PHARMACY LICENSE
MI5315043773OtherSTATE PHARMACY CONTROL LICENSE
MI5315043773OtherSTATE PHARMACY CONTROL LICENSE