MEDICARE: MEDRX SPECIALTY PHARMACY, 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	PHY.6828	LA

General Provider Information

NPI Number	:	1386067007
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MEDRX SPECIALTY PHARMACY, LLC.

Provider Business Mailing Address
First Line	:	P.O. BOX 2188
Second Line	:
City	:	CYPRESS
State	:	TX
Zip	:	77410
Country	:	US
Telephone Number	:	713-303-3189
Fax Number	:	855-848-1141

Provider Business Practice Location Address
First Line	:	4726 E TEXAS ST
Second Line	:	SUITE 230
City	:	BOSSIER CITY
State	:	LA
Zip	:	71111-2545
Country	:	US
Telephone Number	:	855-825-5014
Fax Number	:	855-848-1141

Authorized Official
Title or Position	:	MANAGER/OWNER
Name	:	MR. JERMAINE CHRISTOPHER ALLEN
Credential	:
Telephone Number	:	713-303-3189

Provider Enumeration Date	:	01/31/2014
Last Update Date	:	02/08/2017

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