Provider Demographics
NPI:1437562642
Name:PERFORMSPECIALTY, LLC
Entity Type:Organization
Organization Name:PERFORMSPECIALTY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:E
Authorized Official - Last Name:TOOTLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-937-8561
Mailing Address - Street 1:200 STEVENS DR
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19113-1520
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2416 LAKE ORANGE DR
Practice Address - Street 2:SUTIE 190
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32837-7812
Practice Address - Country:US
Practice Address - Phone:407-956-1220
Practice Address - Fax:844-489-9565
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-05
Last Update Date:2020-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL012043200Medicaid
PA1029314380001Medicaid