Provider Demographics
NPI:1326141417
Name:MEDEX DIRECT
Entity Type:Organization
Organization Name:MEDEX DIRECT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:CLYDE
Authorized Official - Middle Name:
Authorized Official - Last Name:FURUTA
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:877-899-6337
Mailing Address - Street 1:23247 PINEWOOD ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48091-4754
Mailing Address - Country:US
Mailing Address - Phone:877-899-6337
Mailing Address - Fax:877-899-6360
Practice Address - Street 1:23247 PINEWOOD ST
Practice Address - Street 2:SUITE B
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48091-4754
Practice Address - Country:US
Practice Address - Phone:877-899-6337
Practice Address - Fax:877-899-6360
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302023127183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2363048OtherNABP