Healthcare Provider Details

I. General information

NPI: 1205831955
Provider Name (Legal Business Name): AVELLA OF GILBERT, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2005
Last Update Date: 04/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2450 E GUADALUPE RD STE 110
GILBERT AZ
85234-5116
US

IV. Provider business mailing address

1606 W WHISPERING WIND DR
PHOENIX AZ
85085-0678
US

V. Phone/Fax

Practice location:
  • Phone: 480-633-6934
  • Fax: 480-633-6974
Mailing address:
  • Phone: 623-434-1700
  • Fax: 623-434-3673

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberY005083
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: JOHN D MUSIL
Title or Position: CEO
Credential:
Phone: 623-434-3657