Provider Demographics
NPI:1275963209
Name:EXPRESS FOOD & PHARMACY LLC
Entity Type:Organization
Organization Name:EXPRESS FOOD & PHARMACY LLC
Other - Org Name:EXPRESS FOOD & PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:KETAN
Authorized Official - Middle Name:
Authorized Official - Last Name:TRIVEDI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-205-7038
Mailing Address - Street 1:50 UPPER ALABAMA ST SW STE 92
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30303-3105
Mailing Address - Country:US
Mailing Address - Phone:404-818-0075
Mailing Address - Fax:404-818-0077
Practice Address - Street 1:50 UPPER ALABAMA ST SW STE 92
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30303-3105
Practice Address - Country:US
Practice Address - Phone:404-818-0075
Practice Address - Fax:404-818-0077
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-12
Last Update Date:2014-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X
GAPHRE0099773336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2142948OtherPK
GA003144768AMedicaid