Provider Demographics
NPI:1366988206
Name:PROFESSIONAL RX PHARMACY LLC
Entity type:Organization
Organization Name:PROFESSIONAL RX PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MASSIMO
Authorized Official - Middle Name:
Authorized Official - Last Name:CAVALLARO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-203-4797
Mailing Address - Street 1:2560 E SUNSET RD STE 120
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89120-3517
Mailing Address - Country:US
Mailing Address - Phone:702-478-6690
Mailing Address - Fax:888-906-3556
Practice Address - Street 1:2560 E SUNSET RD STE 120
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89120-3517
Practice Address - Country:US
Practice Address - Phone:702-478-6690
Practice Address - Fax:888-906-3556
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-17
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NVPH036723336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2167002OtherPK