Provider Demographics
NPI:1336527217
Name:MED RX PHARMACY INC
Entity Type:Organization
Organization Name:MED RX PHARMACY INC
Other - Org Name:MED RX PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO/PIC
Authorized Official - Prefix:
Authorized Official - First Name:LEROY
Authorized Official - Middle Name:
Authorized Official - Last Name:BANKS
Authorized Official - Suffix:
Authorized Official - Credentials:BS
Authorized Official - Phone:770-316-9815
Mailing Address - Street 1:4153 FLAT SHOALS PKWY STE 106
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30034-4106
Mailing Address - Country:US
Mailing Address - Phone:404-243-5473
Mailing Address - Fax:404-328-1327
Practice Address - Street 1:4153 FLAT SHOALS PKWY STE 106
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30034-4106
Practice Address - Country:US
Practice Address - Phone:404-243-5473
Practice Address - Fax:404-328-1327
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-12
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
GAPHRE0102743336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
2159589OtherPK