MEDICARE: REXTOX CONSULTANT LLC

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	3336C0003X	Community/Retail Pharmacy	PHRE010633	GA

General Provider Information

NPI Number	:	1023500501
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	REXTOX CONSULTANT LLC

Provider Business Mailing Address
First Line	:	7525 COVINGTON HWY STE G
Second Line	:
City	:	STONECREST
State	:	GA
Zip	:	30058-7439
Country	:	US
Telephone Number	:	678-292-6025
Fax Number	:	678-292-6922

Provider Business Practice Location Address
First Line	:	7525 COVINGTON HWY STE G
Second Line	:
City	:	LITHONIA
State	:	GA
Zip	:	30058-7439
Country	:	US
Telephone Number	:	678-292-6025
Fax Number	:	678-292-6922

Authorized Official
Title or Position	:	CEO
Name	:	MR. RAPHAEL OGUNSUSI
Credential	:	PHARMACIST
Telephone Number	:	678-478-9511

Provider Enumeration Date	:	05/31/2018
Last Update Date	:	08/21/2018

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Directions to “REXTOX CONSULTANT LLC ” Practice Location

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