Healthcare Provider Details

I. General information

NPI: 1942203187
Provider Name (Legal Business Name): AETNA SPECIALTY PHARMACY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2005
Last Update Date: 05/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

503 SUNPORT LANE
ORLANDO FL
32809-7874
US

IV. Provider business mailing address

503 SUNPORT LANE
ORLANDO FL
32809-7874
US

V. Phone/Fax

Practice location:
  • Phone: 407-513-6400
  • Fax: 866-329-2779
Mailing address:
  • Phone: 407-513-6400
  • Fax: 866-329-2779

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336H0001X
TaxonomyHome Infusion Therapy Pharmacy
License NumberPH21035
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License NumberPH21035
License Number StateFL

VIII. Authorized Official

Name: JEAN R. CARNEY
Title or Position: SR. PHARMACY OPS MGR
Credential:
Phone: 407-513-6495