PRIME THERAPEUTICS PHARMACY LLC

Provider Demographics

• NPI: 1245241884
• Name: PRIME THERAPEUTICS PHARMACY LLC
• Entity type: Organization
• Organization Name: PRIME THERAPEUTICS PHARMACY LLC
• Other - Org Name: <UNAVAIL>
• Authorized Official - Title/Position: VP & GM SPECIALTY PHARMACY DIST
• Authorized Official - First Name: ANDREW
• Authorized Official - Last Name: GLOVER
• Authorized Official - Phone: 612-777-4940
• Mailing Address - Street 1: 6870 SHADOWRIDGE DR
• Mailing Address - Street 2: SUITE 111
• Mailing Address - City: ORLANDO
• Mailing Address - State: FL
• Mailing Address - Zip Code: 32812-9002
• Mailing Address - Country: US
• Mailing Address - Phone: 866-554-2673
• Mailing Address - Fax: 866-364-2673
• Practice Address - Street 1: 6870 SHADOWRIDGE DR
• Practice Address - Street 2: STE 111
• Practice Address - City: ORLANDO
• Practice Address - State: FL
• Practice Address - Zip Code: 32812-9002
• Practice Address - Country: US
• Practice Address - Phone: 866-554-2673
• Practice Address - Fax: 866-364-2673
• EIN: <UNAVAIL>
• Is Organization Subpart?: No
• Enumeration Date: 2006-08-10
• Last Update Date: 2025-04-11

Provider Licenses

State	License ID	Taxonomies
		333600000X
FL	PH19541	3336S0011X, 3336S0011X

Provider Taxonomies

Primary?	Code	Type	Classification	Specialization
Yes	3336S0011X	Suppliers	Pharmacy	Specialty Pharmacy
No	333600000X	Suppliers	Pharmacy

Provider Identifiers

State	Identifier ID	ID Type	Issuer
FL	031904000	Medicaid
OH	1245241884	Medicaid
WI	1245241884	Medicaid
WA	1245241884	Medicaid
CT	1245241884	Medicaid
TN	1528692	Medicaid
IL	513347297001	Medicaid
PA	10132338040002	Medicaid
ID	1245241884	Medicaid
AZ	589259	Medicaid
MI	1245241884	Medicaid
MD	415778800	Medicaid
MN	1245241884	Medicaid
	2006243	Other	PK
KY	54012687	Medicaid
MO	600200927	Medicaid
VA	1245241884	Medicaid
SC	7F9541	Medicaid
CO	ATN66122	Medicaid
ME	1245241884	Medicaid
VT	1245241884	Medicaid
OK	200412310A	Medicaid
NE	100265185-00	Medicaid
IN	200855460A	Medicaid
NH	30708673	Medicaid
NJ	538884	Medicaid
AK	1612421	Medicaid