Provider Demographics
NPI:1922287804
Name:ADVANT-EDGE HEALTHCARE
Entity Type:Organization
Organization Name:ADVANT-EDGE HEALTHCARE
Other - Org Name:ADVANT EDGE PHARMACY 00002
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:EUSTACIO
Authorized Official - Middle Name:
Authorized Official - Last Name:RIVAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:915-309-9343
Mailing Address - Street 1:14476 HORIZON BLVD
Mailing Address - Street 2:STE J
Mailing Address - City:HORIZON CITY
Mailing Address - State:TX
Mailing Address - Zip Code:79928-8578
Mailing Address - Country:US
Mailing Address - Phone:915-852-8884
Mailing Address - Fax:915-852-1727
Practice Address - Street 1:14476 HORIZON BLVD
Practice Address - Street 2:STE J
Practice Address - City:HORIZON CITY
Practice Address - State:TX
Practice Address - Zip Code:79928-8578
Practice Address - Country:US
Practice Address - Phone:915-852-8884
Practice Address - Fax:915-852-1727
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-29
Last Update Date:2017-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
TX257723336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX145854Medicaid
2100496OtherPK