1245241884 NPI number — PRIME THERAPEUTICS PHARMACY LLC

Table of content: (NPI 1245241884)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245241884 NPI number — PRIME THERAPEUTICS PHARMACY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRIME THERAPEUTICS 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:
6
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:
1245241884
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/11/2025
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:
SUITE 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
Provider Second Line Business Practice Location Address:
STE 111
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:
08/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GLOVER
Authorized Official First Name:
ANDREW
Authorized Official Middle Name:
Authorized Official Title or Position:
VP & GM SPECIALTY PHARMACY DIST
Authorized Official Telephone Number:
612-777-4940

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336S0011X , 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: 031904000 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1245241884 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1245241884 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1245241884 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1245241884 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1528692 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 513347297001 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 10132338040002 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1245241884 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 589259 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1245241884 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 415778800 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1245241884 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2006243 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 54012687 , issued by the state of ( KY ) . 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 ( VA ) . 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: 1245241884 , issued by the state of ( ME ) . This identifiers is of the category "MEDICAID".




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