MEDICARE: ADVANT-EDGE PHARMACY, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3336H0001X	Home Infusion Therapy Pharmacy
2	332B00000X	Durable Medical Equipment & Medical Supplies
3	3336L0003X	Long Term Care Pharmacy
4	333600000X	Pharmacy
5	3336C0003X	Community/Retail Pharmacy	19378	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2091866	OTHER		PK
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1003994518
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ADVANT-EDGE PHARMACY, INC

Provider Business Mailing Address
First Line	:	1576 LOMALAND DR
Second Line	:
City	:	EL PASO
State	:	TX
Zip	:	79935-4202
Country	:	US
Telephone Number	:	915-595-0409
Fax Number	:	915-595-1028

Provider Business Practice Location Address
First Line	:	1576 LOMALAND DR
Second Line	:
City	:	EL PASO
State	:	TX
Zip	:	79935-4202
Country	:	US
Telephone Number	:	915-595-0409
Fax Number	:	915-595-1028

Authorized Official
Title or Position	:	PRESIDENT
Name	:	EUSTACIO RIVAS
Credential	:
Telephone Number	:	915-595-0409

Provider Enumeration Date	:	11/01/2006
Last Update Date	:	11/13/2023

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Directions to “ADVANT-EDGE PHARMACY, INC ” Practice Location

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