Provider Demographics
NPI:1194369777
Name:FRESH RX LLC
Entity Type:Organization
Organization Name:FRESH RX LLC
Other - Org Name:FRESH WELLNESS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ZAW
Authorized Official - Middle Name:
Authorized Official - Last Name:THURA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:626-295-2933
Mailing Address - Street 1:18417 COLIMA RD
Mailing Address - Street 2:
Mailing Address - City:ROWLAND HEIGHTS
Mailing Address - State:CA
Mailing Address - Zip Code:91748-2898
Mailing Address - Country:US
Mailing Address - Phone:626-295-2933
Mailing Address - Fax:626-550-1190
Practice Address - Street 1:18417 COLIMA RD
Practice Address - Street 2:
Practice Address - City:ROWLAND HEIGHTS
Practice Address - State:CA
Practice Address - Zip Code:91748-2898
Practice Address - Country:US
Practice Address - Phone:626-295-2933
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-06
Last Update Date:2021-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACA1194369777Medicaid