Healthcare Provider Details

I. General information

NPI: 1619332145
Provider Name (Legal Business Name): AVITA DRUGS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/29/2015
Last Update Date: 08/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5551 CORPORATE BLVD
BATON ROUGE LA
70808-2567
US

IV. Provider business mailing address

5551 CORPORATE BLVD
BATON ROUGE LA
70808-2567
US

V. Phone/Fax

Practice location:
  • Phone: 844-533-0588
  • Fax: 844-533-0607
Mailing address:
  • Phone: 844-533-0588
  • Fax: 844-533-0607

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberPHY006081IR
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MARSHALL FROST
Title or Position: DIRECTOR OF IT & VENDOR MGMT
Credential: PHARMD
Phone: 803-254-5884