MEDICARE: ADVANTAGE PHARMACY LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	333600000X	Pharmacy
2	3336S0011X	Specialty Pharmacy
3	3336M0002X	Mail Order Pharmacy	5094	TN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	4445498	OTHER		NCPDP PROVIDER IDENTIFICATION NUMBER

General Provider Information

NPI Number	:	1134463425
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ADVANTAGE PHARMACY LLC

Provider Business Mailing Address
First Line	:	2175 BUSINESS CENTER DR
Second Line	:	STE. 6
City	:	MEMPHIS
State	:	TN
Zip	:	38134-5628
Country	:	US
Telephone Number	:	901-881-9770
Fax Number	:	866-488-7820

Provider Business Practice Location Address
First Line	:	2175 BUSINESS CENTER DR STE 6
Second Line	:
City	:	MEMPHIS
State	:	TN
Zip	:	38134-5628
Country	:	US
Telephone Number	:	901-881-9770
Fax Number	:	866-488-7820

Authorized Official
Title or Position	:	PRESIDENT
Name	:	CRAIG GILMORE
Credential	:
Telephone Number	:	800-662-9220

Provider Enumeration Date	:	11/27/2012
Last Update Date	:	11/27/2012

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Directions to “ADVANTAGE PHARMACY LLC ” Practice Location

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