Provider Demographics
NPI:1326059965
Name:EXPRESS MEDS RX LLC
Entity Type:Organization
Organization Name:EXPRESS MEDS RX LLC
Other - Org Name:EXPRESS MEDS RX LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:RICARDO
Authorized Official - Middle Name:
Authorized Official - Last Name:LUACES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:239-936-1041
Mailing Address - Street 1:PO BOX 9830
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84109-9830
Mailing Address - Country:US
Mailing Address - Phone:801-716-4721
Mailing Address - Fax:801-716-4872
Practice Address - Street 1:1860 BOY SCOUT DR
Practice Address - Street 2:STE 201
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-2144
Practice Address - Country:US
Practice Address - Phone:239-274-3269
Practice Address - Fax:239-936-1761
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2011-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH220693336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL31346700Medicaid
1019834OtherNCPDP PROVIDER IDENTIFICATION NUMBER
5777420001Medicare NSC