=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093014573
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MED EX DIRECT, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/23/2011
-----------------------------------------------------
Last Update Date | 03/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13201 STEPHENS RD SUITE D
-----------------------------------------------------
City | WARREN
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48089-4340
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 877-881-3100
-----------------------------------------------------
Fax | 877-899-6360
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13201 STEPHENS RD SUITE D
-----------------------------------------------------
City | WARREN
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48089-4340
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 877-881-3100
-----------------------------------------------------
Fax | 877-899-6360
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. JOHN GALLANT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 877-881-3100
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0004X
-----------------------------------------------------
Taxonomy Name | Compounding Pharmacy
-----------------------------------------------------
License Number | 5301009263
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------