Provider Demographics
NPI:1932272523
Name:MIIVRX LLC
Entity Type:Organization
Organization Name:MIIVRX LLC
Other - Org Name:MIIVRX
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:ROEDER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:989-631-3636
Mailing Address - Street 1:49 E ISABELLA RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48640-8356
Mailing Address - Country:US
Mailing Address - Phone:989-631-3636
Mailing Address - Fax:989-832-6091
Practice Address - Street 1:49 E ISABELLA RD
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48640-8356
Practice Address - Country:US
Practice Address - Phone:989-631-3636
Practice Address - Fax:989-832-6091
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332100000X, 332BC3200X, 332BP3500X, 333600000X, 3336C0004X, 3336S0011X
MI53010105443336H0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
No332100000XSuppliersDepartment of Veterans Affairs (VA) Pharmacy
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2145782OtherPK
MI1710362Medicaid
MI1710362Medicaid