1942203187 NPI number — AETNA SPECIALTY PHARMACY, LLC

Table of content: (NPI 1942203187)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942203187 NPI number — AETNA SPECIALTY PHARMACY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AETNA SPECIALTY 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:
Provider Other Organization Name Type Code:
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:
1942203187
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/19/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
503 SUNPORT LANE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ORLANDO
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32809-7874
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
407-513-6400
Provider Business Mailing Address Fax Number:
866-329-2779

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
503 SUNPORT LANE
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:
32809-7874
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
407-513-6400
Provider Business Practice Location Address Fax Number:
866-329-2779
Provider Enumeration Date:
05/23/2005

Additional Information

Authorized Official

Authorized Official Last Name:
CARNEY
Authorized Official First Name:
JEAN
Authorized Official Middle Name:
R.
Authorized Official Title or Position:
SR. PHARMACY OPS MGR
Authorized Official Telephone Number:
407-513-6495

Provider Taxonomy Codes

  • Taxonomy code: 3336H0001X , with the licence number:  PH21035 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336S0011X , with the licence number: PH21035 , 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: 582713 , issued by the state of ( HI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6029037 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1714655 . This is a "AETNA HEALTHCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 200369680A , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 411068400 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 035123 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3726379 . This is a "AETNA HEALTHCARE HMO CLMS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0720789 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7446672 . This is a "AETNA HEALTHCARE DIEM CLAIM" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0215059 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 030961300 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 35123 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3726379 . This is a "AETNA HEALTHCARE HMO CLAIMS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 7446672 . This is a "AETNA HEALTHCARE DIEM CLM" identifier . This identifiers is of the category "OTHER".
  • Identifier: 807415000 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: PH575FL , issued by the state of ( AK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1016502540001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 38457750 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1942203187 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200077510A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com