Healthcare Provider Details

I. General information

NPI: 1629637129
Provider Name (Legal Business Name): MODERN RX
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2019
Last Update Date: 06/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6330 S EASTERN AVE STE 1A
LAS VEGAS NV
89119-3168
US

IV. Provider business mailing address

6330 S EASTERN AVE STE 1A
LAS VEGAS NV
89119-3168
US

V. Phone/Fax

Practice location:
  • Phone: 702-831-5877
  • Fax:
Mailing address:
  • Phone: 702-831-5877
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: AIMEE BROWN
Title or Position: MANAGER
Credential:
Phone: 510-366-9707