Provider Demographics
NPI:1891970265
Name:MED EX DIRECT LLC
Entity Type:Organization
Organization Name:MED EX DIRECT LLC
Other - Org Name:LTC MED EX DIRECT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:M
Authorized Official - Last Name:GALLANT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:586-353-6337
Mailing Address - Street 1:13201 STEPHENS RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48089-4340
Mailing Address - Country:US
Mailing Address - Phone:586-353-6300
Mailing Address - Fax:877-899-6360
Practice Address - Street 1:13201 STEPHENS RD
Practice Address - Street 2:SUITE C
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48089-4340
Practice Address - Country:US
Practice Address - Phone:586-353-6300
Practice Address - Fax:877-899-6360
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-04
Last Update Date:2015-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53150341443336C0004X, 3336L0003X, 3336M0002X, 3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2370637OtherNCPDP
MI5733370001Medicare NSC