Provider Demographics
NPI:1295987253
Name:ADVANCED SPECIALTY RX LLC
Entity type:Organization
Organization Name:ADVANCED SPECIALTY RX LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BASSAM
Authorized Official - Middle Name:
Authorized Official - Last Name:YOUSSEF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:810-230-8300
Mailing Address - Street 1:4488 W BRISTOL RD STE 350
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48507-3111
Mailing Address - Country:US
Mailing Address - Phone:810-232-2700
Mailing Address - Fax:888-246-0436
Practice Address - Street 1:4488 W BRISTOL RD STE 350
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48507-3111
Practice Address - Country:US
Practice Address - Phone:810-232-2700
Practice Address - Fax:888-246-0436
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-21
Last Update Date:2021-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336S0011X, 3336C0004X, 3336M0003X
MI53010089023336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336M0003XSuppliersPharmacyManaged Care Organization Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2125139OtherPK