Provider Demographics
NPI:1912019928
Name:MEDIEXPRESS PHARMACY CORP
Entity Type:Organization
Organization Name:MEDIEXPRESS PHARMACY CORP
Other - Org Name:MEDIEXPRESS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:LAI
Authorized Official - Middle Name:
Authorized Official - Last Name:KWAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:212-388-9886
Mailing Address - Street 1:78 CLINTON ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10002-3487
Mailing Address - Country:US
Mailing Address - Phone:212-388-9886
Mailing Address - Fax:212-388-1228
Practice Address - Street 1:78 CLINTON ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10002-3487
Practice Address - Country:US
Practice Address - Phone:212-388-9886
Practice Address - Fax:212-388-1228
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2017-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NY0272863336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2064046OtherPK
NY02693254Medicaid
NY02693254Medicaid