Provider Demographics
NPI:1275641649
Name:ADVANCED RX LLC
Entity Type:Organization
Organization Name:ADVANCED RX LLC
Other - Org Name:NEW WALKER'S PROFESSIONAL PHARMACY LTC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:FADI
Authorized Official - Middle Name:
Authorized Official - Last Name:NASERDEAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD, MD
Authorized Official - Phone:313-680-3000
Mailing Address - Street 1:P.O. BOX 660
Mailing Address - Street 2:
Mailing Address - City:DEARBORN HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48127
Mailing Address - Country:US
Mailing Address - Phone:616-374-3190
Mailing Address - Fax:616-374-0921
Practice Address - Street 1:838 4TH AVENUE
Practice Address - Street 2:
Practice Address - City:LAKE ODESSA
Practice Address - State:MI
Practice Address - Zip Code:48849
Practice Address - Country:US
Practice Address - Phone:616-374-3190
Practice Address - Fax:616-374-0921
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-27
Last Update Date:2021-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X
MI53010054453336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI021935001Medicaid
2175188OtherPK
MI2347424Medicaid
MI2347424OtherNABP
MI2347424OtherNABP
MI021935001Medicaid