Provider Demographics
NPI:1063524056
Name:INNOVATIVE RX INC
Entity type:Organization
Organization Name:INNOVATIVE RX INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MAYANK
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-642-0106
Mailing Address - Street 1:275 VICTORIA ST
Mailing Address - Street 2:STE 1F
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92627-1906
Mailing Address - Country:US
Mailing Address - Phone:949-642-0106
Mailing Address - Fax:949-642-5039
Practice Address - Street 1:275 VICTORIA ST
Practice Address - Street 2:STE 1F
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92627-1906
Practice Address - Country:US
Practice Address - Phone:949-642-0106
Practice Address - Fax:949-642-5039
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2009-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY488473336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0525468OtherNCPDP PROVIDER IDENTIFICATION NUMBER