Healthcare Provider Details

I. General information

NPI: 1780811125
Provider Name (Legal Business Name): NEOVANCE SPECIALTY PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2009
Last Update Date: 05/15/2026
Certification Date: 05/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 TECHNOLOGY PARK STE 158
LAKE MARY FL
32746-6205
US

IV. Provider business mailing address

100 TECHNOLOGY PARK STE 158
LAKE MARY FL
32746-6205
US

V. Phone/Fax

Practice location:
  • Phone: 866-842-2147
  • Fax: 866-842-1509
Mailing address:
  • Phone: 866-842-2147
  • Fax: 866-842-1509

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberPH23883
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number StateNULL

VIII. Authorized Official

Name: JEN RICHARD
Title or Position: CHIEF OPERATIONS OFFICER
Credential:
Phone: 866-842-2147