Provider Demographics
NPI:1609221647
Name:MAGELLAN RX PHARMACY, LLC
Entity Type:Organization
Organization Name:MAGELLAN RX PHARMACY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP PHARMACY OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:KUO
Authorized Official - Middle Name:HUNG
Authorized Official - Last Name:WONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:1407-858-6206
Mailing Address - Street 1:2256 S 3600 W STE A
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84119-1124
Mailing Address - Country:US
Mailing Address - Phone:855-271-4810
Mailing Address - Fax:
Practice Address - Street 1:2256 S 3600 W STE A
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84119-1124
Practice Address - Country:US
Practice Address - Phone:855-271-4810
Practice Address - Fax:801-433-6219
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-27
Last Update Date:2023-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9771246-17033336M0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336M0002XSuppliersPharmacyMail Order Pharmacy