Provider Demographics
NPI:1457752032
Name:PROGRESSIVE PHARMA LLC
Entity Type:Organization
Organization Name:PROGRESSIVE PHARMA LLC
Other - Org Name:ALTUS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AUTHORIZED OFFICAL
Authorized Official - Prefix:
Authorized Official - First Name:AMIR
Authorized Official - Middle Name:
Authorized Official - Last Name:MORTAZAVI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-432-6550
Mailing Address - Street 1:5710 LBJ FWY
Mailing Address - Street 2:SUITE 325
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75240-6324
Mailing Address - Country:US
Mailing Address - Phone:972-432-6550
Mailing Address - Fax:214-261-2217
Practice Address - Street 1:1535 WEST LOOP S
Practice Address - Street 2:SUITE 322
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77027-9512
Practice Address - Country:US
Practice Address - Phone:972-432-6550
Practice Address - Fax:214-261-2217
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-15
Last Update Date:2015-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX290693336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2147410OtherPK