=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790799054
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PHARMACY EXPRESS SERVICES INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/29/2006
-----------------------------------------------------
Last Update Date | 04/20/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1817 W BROADWAY
-----------------------------------------------------
City | COUNCIL BLUFFS
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 51501-3823
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 712-322-5885
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 241148
-----------------------------------------------------
City | OMAHA
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68124-5148
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 712-322-5885
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | BRUCE S GOLDBERG
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 712-322-5885
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 1097
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------