Healthcare Provider Details

I. General information

NPI: 1194647206
Provider Name (Legal Business Name): NEOVANCE SPECIALTY PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/29/2026
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5025 TUGGLE RD # 100
MEMPHIS TN
38118-7514
US

IV. Provider business mailing address

5025 TUGGLE RD # 100
MEMPHIS TN
38118-7514
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State

VIII. Authorized Official

Name: NANCY COSTLOW
Title or Position: VP, CLINICAL AND PHARMACY OPERATION
Credential: COSTLOW
Phone: 689-257-3345