Healthcare Provider Details

I. General information

NPI: 1447581913
Provider Name (Legal Business Name): ADVANCED CARE RX PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2010
Last Update Date: 01/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

840 E TWAIN AVE STE 137
LAS VEGAS NV
89169-4025
US

IV. Provider business mailing address

840 E TWAIN AVE STE 137
LAS VEGAS NV
89169-4025
US

V. Phone/Fax

Practice location:
  • Phone: 702-272-2709
  • Fax: 702-405-0673
Mailing address:
  • Phone: 702-272-2709
  • Fax: 702-405-0673

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPH02583
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License NumberPH02583
License Number StateNV

VIII. Authorized Official

Name: EGHE JERRY IGBINOVIA
Title or Position: OWNER
Credential: PHARM. D
Phone: 702-595-6265