Provider Demographics
NPI:1851762769
Name:RR MEDCO LLC
Entity Type:Organization
Organization Name:RR MEDCO LLC
Other - Org Name:HEALTH SOURCE WELLNESS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:
Authorized Official - Last Name:DI IULIO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:754-264-7540
Mailing Address - Street 1:100 E SAMPLE RD
Mailing Address - Street 2:SUITE 320
Mailing Address - City:POMPANO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33064-3554
Mailing Address - Country:US
Mailing Address - Phone:754-264-7540
Mailing Address - Fax:754-222-9389
Practice Address - Street 1:100 E SAMPLE RD STE 320
Practice Address - Street 2:
Practice Address - City:POMPANO BEACH
Practice Address - State:FL
Practice Address - Zip Code:33064-3554
Practice Address - Country:US
Practice Address - Phone:754-264-7540
Practice Address - Fax:754-222-9389
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-19
Last Update Date:2016-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME53109332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site
Provider Identifiers
StateIdentifier IDID TypeIssuer
2155098OtherPK