Provider Demographics
NPI:1508104712
Name:FUSION SPECIALTY PHARMACY INC
Entity Type:Organization
Organization Name:FUSION SPECIALTY PHARMACY INC
Other - Org Name:FUSION SPECIALTY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KOBY
Authorized Official - Middle Name:
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:435-703-9680
Mailing Address - Street 1:1100 CANYON VIEW DR
Mailing Address - Street 2:STE C
Mailing Address - City:SANTA CLARA
Mailing Address - State:UT
Mailing Address - Zip Code:84765-5671
Mailing Address - Country:US
Mailing Address - Phone:435-703-9680
Mailing Address - Fax:855-853-3465
Practice Address - Street 1:1100 CANYON VIEW DR STE C
Practice Address - Street 2:
Practice Address - City:SANTA CLARA
Practice Address - State:UT
Practice Address - Zip Code:84765-5672
Practice Address - Country:US
Practice Address - Phone:435-703-9680
Practice Address - Fax:855-853-3465
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-23
Last Update Date:2020-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20130162613336C0003X
NVPH029513336C0003X
ID21457MS3336C0003X
AK12603336C0003X
KS22-130153336C0003X
COOSP.00061813336C0003X
MTPHA-MOP-LIC-217633336C0003X
HIPMP-9663336C0003X
ORRP-0002986-CS3336C0003X
NY0334013336C0003X
NMPH0000391113336C0003X
OHNRP.022647900-033336C0003X
NJ28RO001423003336C0003X
FLPH305923336C0003X
GAPHNR0010963336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2138783OtherPK
2138783OtherPK