Provider Demographics
NPI:1104919729
Name:EXPRESS MEDS LLC
Entity type:Organization
Organization Name:EXPRESS MEDS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JIDEOFOR
Authorized Official - Middle Name:N
Authorized Official - Last Name:DALLAH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-233-6511
Mailing Address - Street 1:19785 WEST TWELVE MILE ROAD
Mailing Address - Street 2:SUITE 488
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48076
Mailing Address - Country:US
Mailing Address - Phone:248-233-6511
Mailing Address - Fax:248-233-6512
Practice Address - Street 1:28350 GRATIOT AVENUE
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MI
Practice Address - Zip Code:48066
Practice Address - Country:US
Practice Address - Phone:866-561-3018
Practice Address - Fax:586-776-2634
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2008-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
MI5301008495333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4941172Medicaid
MI4941172Medicaid