Provider Demographics
NPI:1063730182
Name:EXPRESS RX LLC
Entity type:Organization
Organization Name:EXPRESS RX LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MOHAMED
Authorized Official - Middle Name:
Authorized Official - Last Name:DABAJA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-399-3565
Mailing Address - Street 1:8343 N WAYNE RD
Mailing Address - Street 2:
Mailing Address - City:WESTLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48185-1351
Mailing Address - Country:US
Mailing Address - Phone:734-956-5275
Mailing Address - Fax:
Practice Address - Street 1:8343 N WAYNE RD
Practice Address - Street 2:
Practice Address - City:WESTLAND
Practice Address - State:MI
Practice Address - Zip Code:48185-1351
Practice Address - Country:US
Practice Address - Phone:734-956-5275
Practice Address - Fax:734-956-5356
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-13
Last Update Date:2010-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010093203336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2374015OtherNCPDP PROVIDER IDENTIFICATION NUMBER