Provider Demographics
NPI:1780811125
Name:NEOVANCE SPECIALTY PHARMACY LLC
Entity type:Organization
Organization Name:NEOVANCE SPECIALTY PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATIONS OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:BALASKAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-522-9877
Mailing Address - Street 1:100 TECHNOLOGY PARK
Mailing Address - Street 2:SUITE 158
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-6297
Mailing Address - Country:US
Mailing Address - Phone:866-842-2147
Mailing Address - Fax:866-842-1509
Practice Address - Street 1:100 TECHNOLOGY PARK STE 158
Practice Address - Street 2:
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-6205
Practice Address - Country:US
Practice Address - Phone:866-842-2147
Practice Address - Fax:866-842-1509
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-12
Last Update Date:2024-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X
FLPH23883333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2120585OtherPK