Basic Information
| Provider Information | |||||||||
| NPI: | 1770090482 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EVENTUS RX LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6912 S QUENTIN ST STE 50 | ||||||||
| Address2: | |||||||||
| City: | CENTENNIAL | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801124531 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7202825325 | ||||||||
| FaxNumber: | 8776760493 | ||||||||
| Practice Location | |||||||||
| Address1: | 11300 LINDBERGH BLVD STE 107 | ||||||||
| Address2: | |||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339138827 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8662492696 | ||||||||
| FaxNumber: | 8663307487 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/03/2018 | ||||||||
| LastUpdateDate: | 11/09/2022 | ||||||||
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| AuthorizedOfficialLastName: | IRIYE | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7202822377 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | AMERITA, INC | ||||||||
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| AuthorizedOfficialCredential: | AO | ||||||||
| NPICertificationDate: | 11/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | PH31110 | FL | N | Suppliers | Pharmacy | 3336H0001X | N | Suppliers | Pharmacy | Home Infusion Therapy Pharmacy | 3336S0011X | N | Suppliers | Pharmacy | Specialty Pharmacy | 3336C0003X | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | NCPDP | 01 | FL | 5736725 | OTHER | PH31110 | 01 | FL | PHARMACY LICENSE | OTHER |