Provider Demographics
NPI:1366627770
Name:MEDISTAT RX, LLC
Entity Type:Organization
Organization Name:MEDISTAT RX, LLC
Other - Org Name:MEDISTAT RX
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:ACKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:855-737-2550
Mailing Address - Street 1:110 E AZALEA AVE
Mailing Address - Street 2:
Mailing Address - City:FOLEY
Mailing Address - State:AL
Mailing Address - Zip Code:36535-2540
Mailing Address - Country:US
Mailing Address - Phone:855-737-2550
Mailing Address - Fax:866-310-2803
Practice Address - Street 1:110 E AZALEA AVE
Practice Address - Street 2:
Practice Address - City:FOLEY
Practice Address - State:AL
Practice Address - Zip Code:36535-2540
Practice Address - Country:US
Practice Address - Phone:251-923-2525
Practice Address - Fax:866-310-2803
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-03
Last Update Date:2014-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0003X
AL1130313336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy
No333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1996235OtherPK