Provider Demographics
NPI:1922415140
Name:PHYSICIAN SPECIALTY PHARMACY LLC
Entity Type:Organization
Organization Name:PHYSICIAN SPECIALTY PHARMACY LLC
Other - Org Name:PHYSICIAN SPECIALTY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:FISHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-462-9555
Mailing Address - Street 1:6258 N W ST
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32505-1903
Mailing Address - Country:US
Mailing Address - Phone:850-462-9555
Mailing Address - Fax:850-462-9554
Practice Address - Street 1:6258 N W ST
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32505-1903
Practice Address - Country:US
Practice Address - Phone:850-462-9555
Practice Address - Fax:850-462-9554
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-21
Last Update Date:2017-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336M0002X
FLPH283083336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2146913OtherPK