Provider Demographics
NPI:1063736304
Name:MEDSOURCE RX PHARMACY LLC
Entity type:Organization
Organization Name:MEDSOURCE RX PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:
Authorized Official - First Name:SAHILY
Authorized Official - Middle Name:
Authorized Official - Last Name:PAOLINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:888-702-2195
Mailing Address - Street 1:9883 S 500 W
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84070-2561
Mailing Address - Country:US
Mailing Address - Phone:801-727-0080
Mailing Address - Fax:855-332-9272
Practice Address - Street 1:9883 S 500 W
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84070-2561
Practice Address - Country:US
Practice Address - Phone:801-727-1979
Practice Address - Fax:855-332-9272
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-16
Last Update Date:2013-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7609917-17033336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2123919OtherPK