Provider Demographics
NPI:1982205654
Name:SEA REX LLC
Entity Type:Organization
Organization Name:SEA REX LLC
Other - Org Name:REXALL ANN ARBOR PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:3RD PARTY COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:CANDI
Authorized Official - Middle Name:
Authorized Official - Last Name:TOLF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:734-214-1234
Mailing Address - Street 1:4301 ORCHARD LAKE RD STE 180-183
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48323-1604
Mailing Address - Country:US
Mailing Address - Phone:248-963-7979
Mailing Address - Fax:
Practice Address - Street 1:5770 PLYMOUTH RD
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48105-9312
Practice Address - Country:US
Practice Address - Phone:734-214-1234
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-08
Last Update Date:2023-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FSRX2846318OtherFLEXSCRIPT