MEDICARE: INNOVATIVE MEDS RX

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	163WD0400X	Diabetes Educator Registered Nurse
2	261QM2500X	Medical Specialty Clinic/Center
3	3336C0003X	Community/Retail Pharmacy	11190	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	3459953	OTHER		NCPDP PROVIDER IDENTIFICATION NUMBER

General Provider Information

NPI Number	:	1700154366
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INNOVATIVE MEDS RX

Provider Business Mailing Address
First Line	:	364 N SOUTH ST
Second Line	:
City	:	MOUNT AIRY
State	:	NC
Zip	:	27030-3532
Country	:	US
Telephone Number	:	336-789-5050
Fax Number	:	336-786-7169

Provider Business Practice Location Address
First Line	:	364 N SOUTH ST
Second Line	:
City	:	MOUNT AIRY
State	:	NC
Zip	:	27030-3532
Country	:	US
Telephone Number	:	336-789-5050
Fax Number	:	336-786-7169

Authorized Official
Title or Position	:	PRESIDENT
Name	:	RICHARD KOS
Credential	:
Telephone Number	:	919-475-8706

Provider Enumeration Date	:	12/09/2011
Last Update Date	:	07/06/2021

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