Healthcare Provider Details

I. General information

NPI: 1629438296
Provider Name (Legal Business Name): EXPRESS DRUGS OF SAVANNAH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/25/2016
Last Update Date: 04/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

824 E DE RENNE AVE
SAVANNAH GA
31405-6717
US

IV. Provider business mailing address

824 E DERENNE AVE
SAVANNAH GA
31405-6717
US

V. Phone/Fax

Practice location:
  • Phone: 912-777-3230
  • Fax: 912-436-6616
Mailing address:
  • Phone: 912-777-3230
  • Fax: 912-436-6616

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHRE010267
License Number StateGA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier2158281
Identifier TypeOTHER
Identifier State
Identifier IssuerPK
# 2
Identifier003173707A
Identifier TypeMEDICAID
Identifier StateGA
Identifier Issuer

VIII. Authorized Official

Name: MINH THAI
Title or Position: MANAGER, AO
Credential: PHARMD
Phone: 917-916-3153