1316996713 NPI number — PRIME THERAPY INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316996713 NPI number — PRIME THERAPY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRIME THERAPY INC
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:
1316996713
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/05/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 794
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BAKER
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32531
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-682-8388
Provider Business Mailing Address Fax Number:
850-682-7463

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4100 S FERDON BLVD
Provider Second Line Business Practice Location Address:
STE A1
Provider Business Practice Location Address City Name:
CRESTVIEW
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32536-5252
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-682-8388
Provider Business Practice Location Address Fax Number:
850-682-7463
Provider Enumeration Date:
05/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ARZAGA
Authorized Official First Name:
SABRA
Authorized Official Middle Name:
LYNN
Authorized Official Title or Position:
OWNER PT
Authorized Official Telephone Number:
850-682-8388

Provider Taxonomy Codes

  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 885901900 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: Y901T . This is a "BCBS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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