Provider Demographics
NPI:1740792449
Name:JEFFERSON RX LLC
Entity Type:Organization
Organization Name:JEFFERSON RX LLC
Other - Org Name:KNIGHT DRUGS - JEFFERSON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:3RD PARTY COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:CANDICE
Authorized Official - Middle Name:
Authorized Official - Last Name:TOLF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-751-7979
Mailing Address - Street 1:6689 ORCHARD LAKE RD STE 168
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322-3404
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8367 E JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48214-2730
Practice Address - Country:US
Practice Address - Phone:313-925-7890
Practice Address - Fax:313-925-7889
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JEFFERSON MANAGEMENT INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-11-02
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5301018163336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FSRX5585884OtherFLEXSCRIPT