Provider Demographics
NPI:1316651482
Name:PRIME SPECIALTY PHARMACY
Entity type:Organization
Organization Name:PRIME SPECIALTY PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:JIGNESH
Authorized Official - Middle Name:
Authorized Official - Last Name:MANDAVIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-204-3819
Mailing Address - Street 1:9622 PENSIVE LN
Mailing Address - Street 2:
Mailing Address - City:WAXHAW
Mailing Address - State:NC
Mailing Address - Zip Code:28173-3800
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10215 MCINTYRE RIDGE RD
Practice Address - Street 2:SUITE 101
Practice Address - City:PINEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28134
Practice Address - Country:US
Practice Address - Phone:301-204-3819
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-12
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy