Healthcare Provider Details

I. General information

NPI: 1841867421
Provider Name (Legal Business Name): SSRX LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2021
Last Update Date: 06/10/2021
Certification Date: 06/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

755 MOUNT VERNON HIGHWAY, NE STE 450
ATLANTA GA
30328-4292
US

IV. Provider business mailing address

6330 WEST LOOP SOUTH SUITE 700, 7TH FLOOR
BELLAIRE TX
77401-2928
US

V. Phone/Fax

Practice location:
  • Phone: 713-660-8888
  • Fax: 713-661-4828
Mailing address:
  • Phone: 832-553-1385
  • Fax: 713-661-4828

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MARK GARY FETCENKO
Title or Position: COO
Credential:
Phone: 713-660-8888