Provider Demographics
NPI:1699223578
Name:IMGRX EAST, LLC
Entity type:Organization
Organization Name:IMGRX EAST, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:GENERAL COUNSEL & COO
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:REW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:510-770-6343
Mailing Address - Street 1:1999 HARRISON ST STE 1530
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94612-4730
Mailing Address - Country:US
Mailing Address - Phone:510-770-6343
Mailing Address - Fax:512-233-5828
Practice Address - Street 1:2195 EUCLID AVE STE 6
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:VA
Practice Address - Zip Code:24201-3655
Practice Address - Country:US
Practice Address - Phone:512-596-2930
Practice Address - Fax:760-859-3614
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-20
Last Update Date:2019-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy