Provider Demographics
NPI:1366672271
Name:GENERIC RX LLC
Entity Type:Organization
Organization Name:GENERIC RX LLC
Other - Org Name:GENERIC RX LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:IAGROSSI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-420-5656
Mailing Address - Street 1:3448 W HILLSBORO BLVD
Mailing Address - Street 2:
Mailing Address - City:DEERFIELD BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33442-9419
Mailing Address - Country:US
Mailing Address - Phone:954-420-5656
Mailing Address - Fax:954-427-8566
Practice Address - Street 1:3448 W HILLSBORO BLVD
Practice Address - Street 2:
Practice Address - City:DEERFIELD BEACH
Practice Address - State:FL
Practice Address - Zip Code:33442-9419
Practice Address - Country:US
Practice Address - Phone:954-420-5656
Practice Address - Fax:954-427-8566
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-27
Last Update Date:2009-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH 241613336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1047352OtherNCPDP PROVIDER IDENTIFICATION NUMBER