Provider Demographics
NPI:1619381134
Name:ADVANTIUM PHARMACY LLC
Entity Type:Organization
Organization Name:ADVANTIUM PHARMACY LLC
Other - Org Name:ADVANCED RX PHARMACY 025
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY PROGRAM ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KATI
Authorized Official - Middle Name:
Authorized Official - Last Name:GAINOUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:925-621-2902
Mailing Address - Street 1:C/O ADVANCED RX MANAGEMENT
Mailing Address - Street 2:4683 CHABOT DRIVE, #200
Mailing Address - City:PLEASANTON
Mailing Address - State:CA
Mailing Address - Zip Code:94588
Mailing Address - Country:US
Mailing Address - Phone:925-621-2909
Mailing Address - Fax:925-269-8423
Practice Address - Street 1:5651 FRIST BLVD STE 717
Practice Address - Street 2:
Practice Address - City:HERMITAGE
Practice Address - State:TN
Practice Address - Zip Code:37076-2061
Practice Address - Country:US
Practice Address - Phone:615-872-9966
Practice Address - Fax:615-872-9967
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-12
Last Update Date:2014-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN00000053603336C0003X
3336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2146606OtherPK