Provider Demographics
NPI:1356790364
Name:PRIME THERAPEUTICS PHARMACY LLC
Entity type:Organization
Organization Name:PRIME THERAPEUTICS PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:
Authorized Official - First Name:PHI
Authorized Official - Middle Name:
Authorized Official - Last Name:TRAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:855-271-4810
Mailing Address - Street 1:2256 S 3600 W STE A
Mailing Address - Street 2:
Mailing Address - City:WEST VALLEY CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84119-1124
Mailing Address - Country:US
Mailing Address - Phone:866-554-2673
Mailing Address - Fax:866-364-2673
Practice Address - Street 1:2256 S 3600 W STE A
Practice Address - Street 2:
Practice Address - City:WEST VALLEY CITY
Practice Address - State:UT
Practice Address - Zip Code:84119-1124
Practice Address - Country:US
Practice Address - Phone:866-554-2673
Practice Address - Fax:866-364-2673
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-09
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336M0002X
UT10303032-17043336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336M0002XSuppliersPharmacyMail Order Pharmacy
No333600000XSuppliersPharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2162441OtherPK
4613560OtherNABP