Provider Demographics
NPI:1558759266
Name:PERFORMSPECIALTY, LLC
Entity Type:Organization
Organization Name:PERFORMSPECIALTY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR COUNSEL
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:TOOTLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-937-8561
Mailing Address - Street 1:2416 LAKE ORANGE DR
Mailing Address - Street 2:SUITE 190
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32837-7812
Mailing Address - Country:US
Mailing Address - Phone:407-956-1220
Mailing Address - Fax:407-738-4802
Practice Address - Street 1:2416 LAKE ORANGE DR
Practice Address - Street 2:SUITE 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:407-738-4802
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PERFORMRX, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-01-05
Last Update Date:2015-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS282043336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL012043200Medicaid
PA1029314380001Medicaid