Healthcare Provider Details

I. General information

NPI: 1790564417
Provider Name (Legal Business Name): AVALON PROFESSIONAL PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2023
Last Update Date: 12/08/2025
Certification Date: 12/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12100 ANNAPOLIS RD UNIT 2
GLENN DALE MD
20769
US

IV. Provider business mailing address

12100 ANNAPOLIS RD UNIT 2
GLENN DALE MD
20769
US

V. Phone/Fax

Practice location:
  • Phone: 301-383-0142
  • Fax: 301-383-0143
Mailing address:
  • Phone: 301-383-0142
  • Fax: 301-383-0143

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MR. JASON C MADUKA
Title or Position: PHARMACY OWNER/PHARMACY MANAGER
Credential: RPH
Phone: 301-383-0142