Healthcare Provider Details

I. General information

NPI: 1629589908
Provider Name (Legal Business Name): AV PHARMA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2017
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1545 UNIVERSITY BLVD N STE C
JACKSONVILLE FL
32211-5229
US

IV. Provider business mailing address

PO BOX 600047
JACKSONVILLE FL
32260-0047
US

V. Phone/Fax

Practice location:
  • Phone: 904-440-0611
  • Fax: 904-323-4083
Mailing address:
  • Phone: 904-440-0611
  • Fax: 904-323-4083

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MR. VIPUL MAMTORA
Title or Position: MEMBER MANAGER
Credential:
Phone: 904-440-0611