1790564417 NPI number — AVALON PROFESSIONAL PHARMACY LLC

Table of content: (NPI 1790564417)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790564417 NPI number — AVALON PROFESSIONAL PHARMACY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AVALON PROFESSIONAL PHARMACY 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:
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:
1790564417
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/18/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12100 ANNAPOLIS RD UNIT 2
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GLENN DALE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20769
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-383-0142
Provider Business Mailing Address Fax Number:
301-383-0143

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12100 ANNAPOLIS RD UNIT 2
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GLENN DALE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20769
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-383-0142
Provider Business Practice Location Address Fax Number:
301-383-0143
Provider Enumeration Date:
09/22/2023

Additional Information

Authorized Official

Authorized Official Last Name:
MADUKA
Authorized Official First Name:
JASON
Authorized Official Middle Name:
C
Authorized Official Title or Position:
PHARMACY OWNER/PHARMACY MANAGER
Authorized Official Telephone Number:
301-383-0142

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 456105800 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com