Provider Demographics
NPI:1508921891
Name:CONCOURSE RX PHARMACY INC
Entity Type:Organization
Organization Name:CONCOURSE RX PHARMACY INC
Other - Org Name:CONCOURSE RX
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO/CFO/SEC./DIR.
Authorized Official - Prefix:
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:
Authorized Official - Last Name:WU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:626-965-5988
Mailing Address - Street 1:18575 E. GALE AVE.
Mailing Address - Street 2:#158
Mailing Address - City:CITY OF INDUSTRY
Mailing Address - State:CA
Mailing Address - Zip Code:91748
Mailing Address - Country:US
Mailing Address - Phone:626-965-5988
Mailing Address - Fax:626-965-6588
Practice Address - Street 1:18575 E. GALE AVE.
Practice Address - Street 2:#158
Practice Address - City:CITY OF INDUSTRY
Practice Address - State:CA
Practice Address - Zip Code:91748
Practice Address - Country:US
Practice Address - Phone:626-965-5988
Practice Address - Fax:626-965-6588
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-27
Last Update Date:2022-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY46886333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA5698450001Medicare NSC