Provider Demographics
NPI:1477547552
Name:ADVANT EDGE PHARMACY, INC
Entity Type:Organization
Organization Name:ADVANT EDGE PHARMACY, INC
Other - Org Name:ADVANT EDGE HME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:EUSTACIO
Authorized Official - Middle Name:
Authorized Official - Last Name:RIVAS
Authorized Official - Suffix:JR
Authorized Official - Credentials:RPH
Authorized Official - Phone:915-595-0409
Mailing Address - Street 1:1576 LOMALAND
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79935
Mailing Address - Country:US
Mailing Address - Phone:915-595-0409
Mailing Address - Fax:915-595-1306
Practice Address - Street 1:1576 LOMALAND DR
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79935-4202
Practice Address - Country:US
Practice Address - Phone:915-595-0409
Practice Address - Fax:915-595-1306
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-06
Last Update Date:2012-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX19378332B00000X, 332BP3500X, 332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX010965401Medicaid
TX016896501Medicaid
TX1279740001Medicare NSC
TX016896501Medicaid