Healthcare Provider Details

I. General information

NPI: 1366627770
Provider Name (Legal Business Name): MEDISTAT RX, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2008
Last Update Date: 12/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 E AZALEA AVE
FOLEY AL
36535-2540
US

IV. Provider business mailing address

110 E AZALEA AVE
FOLEY AL
36535-2540
US

V. Phone/Fax

Practice location:
  • Phone: 251-923-2525
  • Fax: 866-310-2803
Mailing address:
  • Phone: 855-737-2550
  • Fax: 866-310-2803

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number113031
License Number StateAL

VIII. Authorized Official

Name: MARK ACKER
Title or Position: CEO
Credential:
Phone: 855-737-2550