Provider Demographics
NPI:1528730595
Name:CREDENCERX SPECIALTY PHARMACY
Entity type:Organization
Organization Name:CREDENCERX SPECIALTY PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:ANDRE
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLERBY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-358-0917
Mailing Address - Street 1:3465 SANTA FE TRL
Mailing Address - Street 2:
Mailing Address - City:DORAVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30340-2719
Mailing Address - Country:US
Mailing Address - Phone:678-358-0917
Mailing Address - Fax:
Practice Address - Street 1:3465 SANTA FE TRL
Practice Address - Street 2:
Practice Address - City:DORAVILLE
Practice Address - State:GA
Practice Address - Zip Code:30340-2719
Practice Address - Country:US
Practice Address - Phone:678-358-0917
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-29
Last Update Date:2021-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336S0011XSuppliersPharmacySpecialty Pharmacy