1184003311 NPI number — AV PHARMA LLC

Table of content: DAKOTA KEITH MILLER PSS (NPI 1245922012)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184003311 NPI number — AV PHARMA LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AV PHARMA LLC
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:
Provider Other Organization Name Type Code:
6
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:
1184003311
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/20/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 600047
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32260-0047
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:
1545 UNIVERSITY BLVD N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32211-5229
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
844-224-8493
Provider Business Practice Location Address Fax Number:
844-324-8493
Provider Enumeration Date:
05/20/2015

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MAMTORA
Authorized Official First Name:
VIPUL
Authorized Official Middle Name:
B
Authorized Official Title or Position:
MBR MGR
Authorized Official Telephone Number:
844-224-8493

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  PH27581 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336S0011X , with the licence number: PH27581 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 333600000X , with the licence number: PH27581 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 117117700 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".