Basic Information
| Provider Information | |||||||||
| NPI: | 1730220468 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SPECTRUM PHARMACY SERVICES LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | PHARMERICA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 3802 CORPOREX PARK DR. | ||||||||
| Address2: | STE 150 | ||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336191125 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8133186039 | ||||||||
| FaxNumber: | 8008256408 | ||||||||
| Practice Location | |||||||||
| Address1: | 4750 LONGLEY LN STE 204 | ||||||||
| Address2: | |||||||||
| City: | RENO | ||||||||
| State: | NV | ||||||||
| PostalCode: | 895025982 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7758256117 | ||||||||
| FaxNumber: | 7758253840 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2007 | ||||||||
| LastUpdateDate: | 05/17/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | REED | ||||||||
| AuthorizedOfficialFirstName: | STEVEN | ||||||||
| AuthorizedOfficialMiddleName: | S. | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5023942100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PHARMACY CORPORATION OF AMERICA | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336L0003X | PH02018 | NV | N | Suppliers | Pharmacy | Long Term Care Pharmacy | 3336L0003X | PHC02018 | NV | Y | Suppliers | Pharmacy | Long Term Care Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 1730220468 | 05 | NV | MEDICAID | 2989032 | 01 | NCPDP PROVIDER IDENTIFICATION NUMBER | OTHER | PHC02018 | 01 | NV | BOARD OF PHARMACY | OTHER | NRP2563 | 01 | CA | BOARD OF PHARMACY | OTHER | 1730220468 | 05 | CA | MEDICAID |