1558738864 NPI number — MAGELLAN RX PHARMACY LLC

Table of content: (NPI 1558738864)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558738864 NPI number — MAGELLAN RX PHARMACY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MAGELLAN RX PHARMACY LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
MAGELLAN RX PHARMACY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1558738864
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/14/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6870 SHADOWRIDGE DR
Provider Second Line Business Mailing Address:
STE 111
Provider Business Mailing Address City Name:
ORLANDO
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32812-9002
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
866-554-2673
Provider Business Mailing Address Fax Number:
866-364-2673

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6870 SHADOWRIDGE DR STE 111
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ORLANDO
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32812-9002
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
866-554-2673
Provider Business Practice Location Address Fax Number:
866-364-2673
Provider Enumeration Date:
08/24/2015

Additional Information

Authorized Official

Authorized Official Last Name:
WONG
Authorized Official First Name:
KUO
Authorized Official Middle Name:
Authorized Official Title or Position:
VP PHARMACY OPERATIONS
Authorized Official Telephone Number:
866-554-2673

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336M0002X , with the licence number: PH19541 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1528692 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 54012687 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7F9541 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: ATN66122 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 031904000 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 101323804-0002 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1245241884 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 415778800 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 600200927 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1245241884 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200855460A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2153807 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 589259 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100265185-00 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200412310A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 513347297001 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1245241884 , issued by the state of ( ME ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1245241884 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 538884 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1245241884 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".




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