1659857480 NPI number — AVALINA PHARMACY INC

Table of content: (NPI 1659857480)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659857480 NPI number — AVALINA PHARMACY INC

Organization/Personal Information

Employer Identification Number (EIN):
N/A
Provider Organization Name:
AVALINA PHARMACY INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
AVALINA PHARMACY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1659857480
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/16/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3355 HUCKLEBERRY CT S
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SALEM
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97302-3655
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3509 COMMERCIAL ST SE STE 3507
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SALEM
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97302-3829
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-829-0115
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/16/2018

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
KIM
Authorized Official First Name:
JOO HYEON
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
541-829-0115

Provider Taxonomy Codes

  • Taxonomy code: 333600000X , with the licence number:  RP-0003275 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: RP-0003275 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0004X , with the licence number: RP-0003275 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)