PRIME THERAPEUTICS PHARMACY LLC

Provider Demographics

• NPI: 1558738864
• 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: STE 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 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: 2015-08-24
• Last Update Date: 2024-09-16

Provider Licenses

State	License ID	Taxonomies
		333600000X
FL	PH19541	3336M0002X, 3336M0002X

Provider Taxonomies

Primary?	Code	Type	Classification	Specialization
Yes	3336M0002X	Suppliers	Pharmacy	Mail Order Pharmacy
No	333600000X	Suppliers	Pharmacy

Provider Identifiers

State	Identifier ID	ID Type	Issuer
VT	1245241884	Medicaid
OH	1245241884	Medicaid
ID	1245241884	Medicaid
NH	30708673	Medicaid
PA	101323804-0002	Medicaid
IN	200855460A	Medicaid
MD	415778800	Medicaid
AZ	589259	Medicaid
CO	ATN66122	Medicaid
WI	1245241884	Medicaid
AK	1612421	Medicaid
MI	1245241884	Medicaid
KY	54012687	Medicaid
SC	7F9541	Medicaid
FL	031904000	Medicaid
ME	1245241884	Medicaid
IL	513347297001	Medicaid
WA	1245241884	Medicaid
CT	1245241884	Medicaid
TN	1528692	Medicaid
OK	200412310A	Medicaid
	2153807	Other	PK
NJ	538884	Medicaid
MN	1245241884	Medicaid
NE	100265185-00	Medicaid
VA	1245241884	Medicaid
MO	600200927	Medicaid