AETNA SPECIALTY PHARMACY, LLC

Provider Demographics

• NPI: 1942203187
• Name: AETNA SPECIALTY PHARMACY, LLC
• Entity Type: Organization
• Organization Name: AETNA SPECIALTY PHARMACY, LLC
• Authorized Official - Title/Position: SR. PHARMACY OPS MGR
• Authorized Official - First Name: JEAN
• Authorized Official - Middle Name: R
• Authorized Official - Last Name: CARNEY
• Authorized Official - Phone: 407-513-6495
• Mailing Address - Street 1: 503 SUNPORT LANE
• Mailing Address - City: ORLANDO
• Mailing Address - State: FL
• Mailing Address - Zip Code: 32809-7874
• Mailing Address - Country: US
• Mailing Address - Phone: 407-513-6400
• Mailing Address - Fax: 866-329-2779
• Practice Address - Street 1: 503 SUNPORT LANE
• Practice Address - City: ORLANDO
• Practice Address - State: FL
• Practice Address - Zip Code: 32809-7874
• Practice Address - Country: US
• Practice Address - Phone: 407-513-6400
• Practice Address - Fax: 866-329-2779
• EIN: <UNAVAIL>
• Is Organization Subpart?: No
• Enumeration Date: 2005-05-23
• Last Update Date: 2014-05-19

Provider Licenses

State	License ID	Taxonomies
FL	PH21035	3336H0001X, 3336S0011X

Provider Taxonomies

Primary?	Code	Type	Classification	Specialization
Yes	3336S0011X	Suppliers	Pharmacy	Specialty Pharmacy
No	3336H0001X	Suppliers	Pharmacy	Home Infusion Therapy Pharmacy

Provider Identifiers

State	Identifier ID	ID Type	Issuer
HI	582713	Medicaid
WA	6029037	Medicaid
	1714655	Other	AETNA HEALTHCARE
KS	200369680A	Medicaid
MD	411068400	Medicaid
AZ	035123	Medicaid
	3726379	Other	AETNA HEALTHCARE HMO CLMS
IA	0720789	Medicaid
	7446672	Other	AETNA HEALTHCARE DIEM CLAIM
MT	0215059	Medicaid
FL	030961300	Medicaid
AZ	35123	Medicaid
	3726379	Other	AETNA HEALTHCARE HMO CLAIMS
	7446672	Other	AETNA HEALTHCARE DIEM CLM
ID	807415000	Medicaid
AK	PH575FL	Medicaid
PA	1016502540001	Medicaid
NM	38457750	Medicaid
VA	1942203187	Medicaid
OK	200077510A	Medicaid
SC	7F1035	Medicaid
MN	057738300	Medicaid
NV	100508643	Medicaid
IN	200808960A	Medicaid
ME	432182200	Medicaid
PA	1016502540001	Medicaid
SC	7F1035	Medicaid
	5328000002	Medicare PIN
	7446672	Other	AETNA HEALTHCARE DIEM CLM
IN	200808960A	Medicaid