Healthcare Provider Details

I. General information

NPI: 1619381134
Provider Name (Legal Business Name): ADVANTIUM PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2014
Last Update Date: 11/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5651 FRIST BLVD STE 717
HERMITAGE TN
37076-2061
US

IV. Provider business mailing address

C/O ADVANCED RX MANAGEMENT 4683 CHABOT DRIVE, #200
PLEASANTON CA
94588
US

V. Phone/Fax

Practice location:
  • Phone: 615-872-9966
  • Fax: 615-872-9967
Mailing address:
  • Phone: 925-621-2909
  • Fax: 925-269-8423

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number0000005360
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: KATI GAINOUS
Title or Position: PHARMACY PROGRAM ADMINISTRATOR
Credential:
Phone: 925-621-2902