Healthcare Provider Details

I. General information

NPI: 1285139030
Provider Name (Legal Business Name): COFFEE RX LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/26/2018
Last Update Date: 08/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 S MAYS ST STE 100
ROUND ROCK TX
78664
US

IV. Provider business mailing address

106 S MAYS ST STE 100
ROUND ROCK TX
78664-5850
US

V. Phone/Fax

Practice location:
  • Phone: 512-238-1146
  • Fax: 512-238-1148
Mailing address:
  • Phone: 512-238-1146
  • Fax: 512-238-1148

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number31891
License Number StateTX

VIII. Authorized Official

Name: VAN COWAN
Title or Position: PHARMACIST IN CHARGE/AO
Credential:
Phone: 512-466-2966