Provider Demographics
NPI:1225463169
Name:INNOVATIVE RX LLC
Entity Type:Organization
Organization Name:INNOVATIVE RX LLC
Other - Org Name:INNOVATIVE RX LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:ANGELEE
Authorized Official - Middle Name:
Authorized Official - Last Name:DEAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-355-5176
Mailing Address - Street 1:12176 S 1000 E
Mailing Address - Street 2:STE 2
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020-9734
Mailing Address - Country:US
Mailing Address - Phone:801-355-5176
Mailing Address - Fax:801-606-7358
Practice Address - Street 1:12176 S 1000 E
Practice Address - Street 2:STE 2
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020-9734
Practice Address - Country:US
Practice Address - Phone:801-355-5176
Practice Address - Fax:801-606-7358
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-11
Last Update Date:2016-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
UT9762264-17033336C0003X
UT8749606-17043336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2159935OtherPK