=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194647206
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NEOVANCE SPECIALTY PHARMACY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/29/2026
-----------------------------------------------------
Last Update Date | 07/29/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5025 TUGGLE RD # 100
-----------------------------------------------------
City | MEMPHIS
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38118-7514
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 866-842-2147
-----------------------------------------------------
Fax | 866-842-2147
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5025 TUGGLE RD # 100
-----------------------------------------------------
City | MEMPHIS
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38118-7514
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 866-842-2147
-----------------------------------------------------
Fax | 866-842-2147
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP, CLINICAL AND PHARMACY OPERATION
-----------------------------------------------------
Name | NANCY COSTLOW
-----------------------------------------------------
Credential | COSTLOW
-----------------------------------------------------
Telephone | 689-257-3345
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------