Healthcare Provider Details

I. General information

NPI: 1366447005
Provider Name (Legal Business Name): AVELLA OF PHOENIX II, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2005
Last Update Date: 09/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5040 N 15TH AVE STE 102
PHOENIX AZ
85015-3329
US

IV. Provider business mailing address

1606 W WHISPERING WIND DR
PHOENIX AZ
85085-0678
US

V. Phone/Fax

Practice location:
  • Phone: 602-277-3181
  • Fax: 602-277-3418
Mailing address:
  • Phone: 623-434-1700
  • Fax: 623-434-3676

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberY005091
License Number StateAZ

VIII. Authorized Official

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