MEDICARE: NEOVANCE 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	3336C0003X	Community/Retail Pharmacy
2	333600000X	Pharmacy	PH23883	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2120585	OTHER		PK

General Provider Information

NPI Number	:	1780811125
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NEOVANCE SPECIALTY PHARMACY LLC

Provider Business Mailing Address
First Line	:	100 TECHNOLOGY PARK
Second Line	:	SUITE 158
City	:	LAKE MARY
State	:	FL
Zip	:	32746-6297
Country	:	US
Telephone Number	:	866-842-2147
Fax Number	:	866-842-1509

Provider Business Practice Location Address
First Line	:	100 TECHNOLOGY PARK STE 158
Second Line	:
City	:	LAKE MARY
State	:	FL
Zip	:	32746-6205
Country	:	US
Telephone Number	:	866-842-2147
Fax Number	:	866-842-1509

Authorized Official
Title or Position	:	CHIEF OPERATIONS OFFICER
Name	:	MARY BALASKAS
Credential	:
Telephone Number	:	312-522-9877

Provider Enumeration Date	:	06/12/2009
Last Update Date	:	09/02/2025

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Directions to “NEOVANCE SPECIALTY PHARMACY LLC ” Practice Location

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