MAGELLAN RX PHARMACY LLC

Provider Demographics

• NPI: 1245241884
• Name: MAGELLAN RX PHARMACY LLC
• Entity Type: Organization
• Organization Name: MAGELLAN RX PHARMACY LLC
• Other - Org Name: MAGELLAN RX PHARMACY
• Other - Org Type: Doing Business As
• Authorized Official - Title/Position: VP PHARMACY OPERATIONS
• Authorized Official - First Name: KUO
• Authorized Official - Last Name: WONG
• Authorized Official - Credentials: RPH
• Authorized Official - Phone: 866-554-2673
• Mailing Address - Street 1: 6870 SHADOWRIDGE DR
• Mailing Address - Street 2: SUITE 111
• Mailing Address - City: ORLANDO
• Mailing Address - State: FL
• Mailing Address - Zip Code: 32812-9002
• Mailing Address - Country: US
• Mailing Address - Phone: 866-554-2673
• Mailing Address - Fax: 866-364-2673
• Practice Address - Street 1: 6870 SHADOWRIDGE DR
• Practice Address - Street 2: STE 111
• Practice Address - City: ORLANDO
• Practice Address - State: FL
• Practice Address - Zip Code: 32812-9002
• Practice Address - Country: US
• Practice Address - Phone: 866-554-2673
• Practice Address - Fax: 866-364-2673
• EIN: <UNAVAIL>
• Is Organization Subpart?: No
• Enumeration Date: 2006-08-10
• Last Update Date: 2023-03-14

Provider Licenses

State	License ID	Taxonomies
		333600000X
FL	PH19541	3336S0011X, 3336S0011X

Provider Taxonomies

Primary?	Code	Type	Classification	Specialization
Yes	3336S0011X	Suppliers	Pharmacy	Specialty Pharmacy
No	333600000X	Suppliers	Pharmacy

Provider Identifiers

State	Identifier ID	ID Type	Issuer
WI	1245241884	Medicaid
ME	1245241884	Medicaid
WA	1245241884	Medicaid
PA	10132338040002	Medicaid
	2006243	Other	PK
OH	1245241884	Medicaid
VA	1245241884	Medicaid
VT	1245241884	Medicaid
IN	200855460A	Medicaid
NH	30708673	Medicaid
NE	100265185-00	Medicaid
MI	1245241884	Medicaid
MN	1245241884	Medicaid
IL	513347297001	Medicaid
NJ	538884	Medicaid
FL	031904000	Medicaid
AK	1612421	Medicaid
OK	200412310A	Medicaid
AZ	589259	Medicaid
CO	ATN66122	Medicaid
CT	1245241884	Medicaid
ID	1245241884	Medicaid
MD	415778800	Medicaid
KY	54012687	Medicaid
MO	600200927	Medicaid
TN	1528692	Medicaid
SC	7F9541	Medicaid