1962816223 NPI number — AVITA DRUGS LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962816223 NPI number — AVITA DRUGS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AVITA DRUGS 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:
1962816223
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/02/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5551 CORPORATE BLVD
Provider Second Line Business Mailing Address:
SUITE 102
Provider Business Mailing Address City Name:
BATON ROUGE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70808-2567
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
225-924-1930
Provider Business Mailing Address Fax Number:
225-924-2620

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5551 CORPORATE BLVD STE 102
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BATON ROUGE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70808-2512
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
225-924-1930
Provider Business Practice Location Address Fax Number:
225-924-2620
Provider Enumeration Date:
06/16/2014

Additional Information

Authorized Official

Authorized Official Last Name:
FROST
Authorized Official First Name:
MARSHALL
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF IT & VENDOR MGMT
Authorized Official Telephone Number:
803-254-5884

Provider Taxonomy Codes

  • Taxonomy code: 3336S0011X , with the licence number:  PHY.006081-IR , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2146281 . This is a "PK" identifier . This identifiers is of the category "OTHER".




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