Provider Demographics
NPI:1851480404
Name:OPTUMRX PHARMACY OF NEVADA, INC.
Entity Type:Organization
Organization Name:OPTUMRX PHARMACY OF NEVADA, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:EUGENE
Authorized Official - Last Name:BURR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:712-310-4701
Mailing Address - Street 1:1945 LAS VEGAS BOULEVARD SOUTH
Mailing Address - Street 2:ATTN: RENA DAWN CARRERA
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89104
Mailing Address - Country:US
Mailing Address - Phone:702-650-4417
Mailing Address - Fax:702-369-5940
Practice Address - Street 1:1945 LAS VEGAS BLVD S
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89104-1310
Practice Address - Country:US
Practice Address - Phone:702-650-4417
Practice Address - Fax:702-369-5940
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-12
Last Update Date:2024-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0003X
NVPH021913336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2052204OtherPK