Provider Demographics
NPI:1992958854
Name:EXPRESSWAY PHARMACY LLC
Entity type:Organization
Organization Name:EXPRESSWAY PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:
Authorized Official - First Name:MARIO
Authorized Official - Middle Name:
Authorized Official - Last Name:TREVINO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:956-464-7600
Mailing Address - Street 1:702 E EXPRESSWAY 83
Mailing Address - Street 2:STE A1
Mailing Address - City:DONNA
Mailing Address - State:TX
Mailing Address - Zip Code:78537-2741
Mailing Address - Country:US
Mailing Address - Phone:956-464-7600
Mailing Address - Fax:956-464-7601
Practice Address - Street 1:702 E EXPRESSWAY 83
Practice Address - Street 2:STE A1
Practice Address - City:DONNA
Practice Address - State:TX
Practice Address - Zip Code:78537-2741
Practice Address - Country:US
Practice Address - Phone:956-464-7600
Practice Address - Fax:956-464-7601
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-23
Last Update Date:2012-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX262263336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4550302OtherNCPDP PROVIDER IDENTIFICATION NUMBER