Healthcare Provider Details

I. General information

NPI: 1134685241
Provider Name (Legal Business Name): MGP RX, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2019
Last Update Date: 12/17/2019
Certification Date: 12/17/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1951 CANTON RD STE 290
MARIETTA GA
30066-6300
US

IV. Provider business mailing address

8242 ALEXANDRIA PIKE
ALEXANDRIA KY
41001-1162
US

V. Phone/Fax

Practice location:
  • Phone: 859-391-4668
  • Fax:
Mailing address:
  • Phone: 470-443-2268
  • Fax: 888-298-6561

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 Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: ZEESHAN HAQ
Title or Position: PARTNER
Credential:
Phone: 832-895-7125