Provider Demographics
NPI:1053486795
Name:POLARIS SPECIALTY PHARMACY LLC
Entity Type:Organization
Organization Name:POLARIS SPECIALTY PHARMACY LLC
Other - Org Name:POLARIS SPECIALTY RX
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF REVENUE
Authorized Official - Prefix:
Authorized Official - First Name:GINA
Authorized Official - Middle Name:
Authorized Official - Last Name:HUNT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:800-589-9747
Mailing Address - Street 1:2900 NW 60TH ST
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33309-1774
Mailing Address - Country:US
Mailing Address - Phone:800-589-9747
Mailing Address - Fax:954-923-9261
Practice Address - Street 1:410 CLOVERLEAF DRIVE
Practice Address - Street 2:
Practice Address - City:BALDWIN PARK
Practice Address - State:CA
Practice Address - Zip Code:91706-6511
Practice Address - Country:US
Practice Address - Phone:626-626-9400
Practice Address - Fax:626-626-9840
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-21
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0003X, 3336L0003X, 3336S0011X, 3336L0003X
CAPHY45588332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Yes3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1053486795Medicaid
CA1053486795Medicaid
CA4727540001Medicare NSC