Healthcare Provider Details

I. General information

NPI: 1275641649
Provider Name (Legal Business Name): ADVANCED RX LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/27/2006
Last Update Date: 08/16/2021
Certification Date: 08/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

838 4TH AVENUE
LAKE ODESSA MI
48849
US

IV. Provider business mailing address

P.O. BOX 660
DEARBORN HEIGHTS MI
48127
US

V. Phone/Fax

Practice location:
  • Phone: 616-374-3190
  • Fax: 616-374-0921
Mailing address:
  • Phone: 616-374-3190
  • Fax: 616-374-0921

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number5301005445
License Number StateMI

VIII. Authorized Official

Name: DR. FADI NASERDEAN
Title or Position: PRESIDENT
Credential: PHARMD, MD
Phone: 313-680-3000