MEDICARE: RYAN ADAM 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

General Provider Information

NPI Number	:	1568046399
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RYAN ADAM PHARMA LLC

Provider Business Mailing Address
First Line	:	5901 S COOPER ST STE 600
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76017-4447
Country	:	US
Telephone Number	:	817-583-6962
Fax Number	:	817-583-6963

Provider Business Practice Location Address
First Line	:	5901 S COOPER ST STE 600
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76017-4447
Country	:	US
Telephone Number	:	817-583-6962
Fax Number	:	817-583-6963

Authorized Official
Title or Position	:	PIC
Name	:	MR. AHMED ELTEGY
Credential	:	RPH
Telephone Number	:	682-367-9008

Provider Enumeration Date	:	05/07/2021
Last Update Date	:	05/07/2021

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