Provider Demographics
NPI:1760843734
Name:EXPRESS DISCOUNT PHARMACY LLC
Entity Type:Organization
Organization Name:EXPRESS DISCOUNT PHARMACY LLC
Other - Org Name:EXPRESS DISCOUNT PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST IN-CHARGE/MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:PAVITHRAN
Authorized Official - Middle Name:
Authorized Official - Last Name:GUJJA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:302-575-9891
Mailing Address - Street 1:4528 KIRKWOOD HWY
Mailing Address - Street 2:STE A
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19808-5126
Mailing Address - Country:US
Mailing Address - Phone:302-575-9891
Mailing Address - Fax:302-575-9893
Practice Address - Street 1:4528 KIRKWOOD HWY STE A
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19808-5126
Practice Address - Country:US
Practice Address - Phone:302-575-9891
Practice Address - Fax:302-575-9893
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-17
Last Update Date:2022-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X, 3336S0011X
DEA3-00010003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE1760843734Medicaid
2158882OtherPK
7556720001Medicare NSC