MEDICARE: PROGRESSIVE PHARMA 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	29069	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2147410	OTHER		PK

General Provider Information

NPI Number	:	1457752032
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROGRESSIVE PHARMA LLC

Provider Business Mailing Address
First Line	:	5710 LBJ FWY
Second Line	:	SUITE 325
City	:	DALLAS
State	:	TX
Zip	:	75240-6324
Country	:	US
Telephone Number	:	972-432-6550
Fax Number	:	214-261-2217

Provider Business Practice Location Address
First Line	:	1535 WEST LOOP S
Second Line	:	SUITE 322
City	:	HOUSTON
State	:	TX
Zip	:	77027-9512
Country	:	US
Telephone Number	:	972-432-6550
Fax Number	:	214-261-2217

Authorized Official
Title or Position	:	AUTHORIZED OFFICAL
Name	:	AMIR MORTAZAVI
Credential	:
Telephone Number	:	972-432-6550

Provider Enumeration Date	:	09/15/2014
Last Update Date	:	01/12/2015

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Directions to “PROGRESSIVE PHARMA LLC ” Practice Location

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