Provider Demographics
NPI:1346481629
Name:MED EX
Entity Type:Organization
Organization Name:MED EX
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACY ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:BRANTLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-739-1309
Mailing Address - Street 1:PO BOX 10890
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32247-0890
Mailing Address - Country:US
Mailing Address - Phone:904-739-1309
Mailing Address - Fax:904-739-1310
Practice Address - Street 1:6500 CRILL AVE
Practice Address - Street 2:
Practice Address - City:PALATKA
Practice Address - State:FL
Practice Address - Zip Code:32177-6807
Practice Address - Country:US
Practice Address - Phone:904-739-1309
Practice Address - Fax:904-739-1310
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-16
Last Update Date:2009-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME54477305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization