Provider Demographics
NPI:1144771007
Name:EDGEWOODRX LLC
Entity Type:Organization
Organization Name:EDGEWOODRX LLC
Other - Org Name:EDGEWOOD PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT / PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:KEYUR
Authorized Official - Middle Name:
Authorized Official - Last Name:MODI
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:281-993-4779
Mailing Address - Street 1:186 S FRIENDSWOOD DR
Mailing Address - Street 2:
Mailing Address - City:FRIENDSWOOD
Mailing Address - State:TX
Mailing Address - Zip Code:77546-3915
Mailing Address - Country:US
Mailing Address - Phone:281-993-4779
Mailing Address - Fax:832-569-4756
Practice Address - Street 1:186 S FRIENDSWOOD DR
Practice Address - Street 2:
Practice Address - City:FRIENDSWOOD
Practice Address - State:TX
Practice Address - Zip Code:77546-3915
Practice Address - Country:US
Practice Address - Phone:281-993-4779
Practice Address - Fax:832-569-4756
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-16
Last Update Date:2021-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX31057333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2165750OtherPK
TX149557Medicaid