Healthcare Provider Details

I. General information

NPI: 1245241884
Provider Name (Legal Business Name): PRIME THERAPEUTICS PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2006
Last Update Date: 04/11/2025
Certification Date: 04/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6870 SHADOWRIDGE DR STE 111
ORLANDO FL
32812-9002
US

IV. Provider business mailing address

6870 SHADOWRIDGE DR SUITE 111
ORLANDO FL
32812-9002
US

V. Phone/Fax

Practice location:
  • Phone: 866-554-2673
  • Fax: 866-364-2673
Mailing address:
  • Phone: 866-554-2673
  • Fax: 866-364-2673

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License NumberPH19541
License Number StateFL

VIII. Authorized Official

Name: ANDREW GLOVER
Title or Position: VP & GM SPECIALTY PHARMACY DIST
Credential:
Phone: 612-777-4940