| Entity Name: | PRIME THERAPEUTICS PHARMACY LLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Foreign Limited Liability Co. |
| Status: | Active |
| Date Filed: | 26 Mar 2003 (22 years ago) |
| Last Event: | LC NAME CHANGE |
| Event Date Filed: | 25 Sep 2024 (4 months ago) |
| Document Number: | M03000000970 |
| FEI/EIN Number | 020676924 |
| Address: | 2256 S 3600 W, Suite A, Salt Lake City, UT, 84119, US |
| Mail Address: | 2256 S 3600 W, Suite A, Salt Lake City, UT, 84119, US |
| Place of Formation: | DELAWARE |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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| 1558738864 | 2015-08-24 | 2024-09-16 | 6870 SHADOWRIDGE DR, STE 111, ORLANDO, FL, 328129002, US | 6870 SHADOWRIDGE DR STE 111, ORLANDO, FL, 328129002, US | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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| Phone | +1 866-554-2673 |
| Fax | 8663642673 |
Authorized person
| Name | ANDREW GLOVER |
| Role | VP & GM SPECIALTY PHARMACY DIST |
| Phone | 6127774940 |
Taxonomy
| Taxonomy Code | 333600000X - Pharmacy |
| Is Primary | No |
| Taxonomy Code | 3336M0002X - Mail Order Pharmacy |
| License Number | PH19541 |
| State | FL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 1245241884 |
| State | VT |
| Issuer | MEDICAID |
| Number | 1245241884 |
| State | OH |
| Issuer | MEDICAID |
| Number | 1245241884 |
| State | ID |
| Issuer | MEDICAID |
| Number | 30708673 |
| State | NH |
| Issuer | MEDICAID |
| Number | 101323804-0002 |
| State | PA |
| Issuer | MEDICAID |
| Number | 200855460A |
| State | IN |
| Issuer | MEDICAID |
| Number | 415778800 |
| State | MD |
| Issuer | MEDICAID |
| Number | 589259 |
| State | AZ |
| Issuer | MEDICAID |
| Number | ATN66122 |
| State | CO |
| Issuer | MEDICAID |
| Number | 1245241884 |
| State | WI |
| Issuer | MEDICAID |
| Number | 1612421 |
| State | AK |
| Issuer | MEDICAID |
| Number | 1245241884 |
| State | MI |
| Issuer | MEDICAID |
| Number | 54012687 |
| State | KY |
| Issuer | MEDICAID |
| Number | 7F9541 |
| State | SC |
| Issuer | MEDICAID |
| Number | 031904000 |
| State | FL |
| Issuer | MEDICAID |
| Number | 1245241884 |
| State | ME |
| Issuer | MEDICAID |
| Number | 513347297001 |
| State | IL |
| Issuer | MEDICAID |
| Number | 1245241884 |
| State | WA |
| Issuer | MEDICAID |
| Number | 1245241884 |
| State | CT |
| Issuer | MEDICAID |
| Number | 1528692 |
| State | TN |
| Issuer | MEDICAID |
| Number | 200412310A |
| State | OK |
| Issuer | PK |
| Number | 2153807 |
| Issuer | MEDICAID |
| Number | 538884 |
| State | NJ |
| Issuer | MEDICAID |
| Number | 1245241884 |
| State | MN |
| Issuer | MEDICAID |
| Number | 100265185-00 |
| State | NE |
| Issuer | MEDICAID |
| Number | 1245241884 |
| State | VA |
| Issuer | MEDICAID |
| Number | 600200927 |
| State | MO |
| Name | Role |
|---|---|
| C T CORPORATION SYSTEM | Agent |
| Name | Role | Address |
|---|---|---|
| Glover Andrew | Manager | 2256 S 3600 W, Salt Lake City, UT, 84119 |
| Palmisano Anthony Jr. | Manager | 2256 S 3600 W, Salt Lake City, UT, 84119 |
| Tveit Kristen | Manager | 2256 S 3600 W, Salt Lake City, UT, 84119 |
| Kamal Mostafa | Manager | 2256 S 3600 W, Salt Lake City, UT, 84119 |
| Registration Number | Fictitious Name | Status | Filed Date | Expiration Date | Cancellation Date | Mailing Address |
|---|---|---|---|---|---|---|
| G15000020360 | MAGELLAN RX MANAGEMENT | EXPIRED | 2015-02-25 | 2020-12-31 | No data | 6950 COLUMBIA GATEWAY DRIVE, COLUMBIA, MD, 21046 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| LC NAME CHANGE | 2024-09-25 | PRIME THERAPEUTICS PHARMACY LLC | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2024-05-07 | 1200 SOUTH PINE ISLAND ROAD, PLANTATION, FL 33324 | No data |
| LC STMNT OF RA/RO CHG | 2024-05-07 | No data | No data |
| REGISTERED AGENT NAME CHANGED | 2024-05-07 | C T CORPORATION SYSTEM | No data |
| CHANGE OF PRINCIPAL ADDRESS | 2023-03-14 | 2256 S 3600 W, Suite A, Salt Lake City, UT 84119 | No data |
| CHANGE OF MAILING ADDRESS | 2023-03-14 | 2256 S 3600 W, Suite A, Salt Lake City, UT 84119 | No data |
| LC NAME CHANGE | 2015-02-13 | MAGELLAN RX PHARMACY, LLC | No data |
| REINSTATEMENT | 2005-10-10 | No data | No data |
| REVOKED FOR ANNUAL REPORT | 2005-09-16 | No data | No data |
| Name | Date |
|---|---|
| LC Name Change | 2024-09-25 |
| CORLCRACHG | 2024-05-07 |
| ANNUAL REPORT | 2024-05-01 |
| ANNUAL REPORT | 2023-03-14 |
| ANNUAL REPORT | 2022-04-28 |
| ANNUAL REPORT | 2021-04-25 |
| ANNUAL REPORT | 2020-06-08 |
| ANNUAL REPORT | 2019-04-10 |
| ANNUAL REPORT | 2018-04-20 |
| ANNUAL REPORT | 2017-04-14 |
Date of last update: 01 Feb 2025
Sources: Florida Department of State
