MEDICARE: MILLENNIUM SPECIALTY 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	3336C0004X	Compounding Pharmacy
2	3336C0003X	Community/Retail Pharmacy
3	333600000X	Pharmacy	PH30593	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2167636	OTHER		PK

General Provider Information

NPI Number	:	1225575020
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MILLENNIUM SPECIALTY PHARMACY LLC

Provider Business Mailing Address
First Line	:	110 S ORLANDO AVE STE 5
Second Line	:
City	:	WINTER PARK
State	:	FL
Zip	:	32789-3656
Country	:	US
Telephone Number	:	407-616-1327
Fax Number	:

Provider Business Practice Location Address
First Line	:	110 S ORLANDO AVE STE 5
Second Line	:
City	:	WINTER PARK
State	:	FL
Zip	:	32789-3656
Country	:	US
Telephone Number	:	407-616-1327
Fax Number	:

Authorized Official
Title or Position	:	PHARMACIST/OWNER
Name	:	TAM TU
Credential	:
Telephone Number	:	407-616-1327

Provider Enumeration Date	:	01/31/2017
Last Update Date	:	02/20/2017

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