Healthcare Provider Details

I. General information

NPI: 1992248702
Provider Name (Legal Business Name): ANOVORX GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2016
Last Update Date: 04/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1710 SHELBY OAKS DR N STE 5
MEMPHIS TN
38134-7403
US

IV. Provider business mailing address

1710 SHELBY OAKS DR N SUITE 5
MEMPHIS TN
38134-7403
US

V. Phone/Fax

Practice location:
  • Phone: 901-201-5470
  • Fax: 901-201-5465
Mailing address:
  • Phone: 901-201-5470
  • Fax: 901-201-5465

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number2017009958
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number5905
License Number StateTN
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberOS02761
License Number StateAR
# 4
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number15077/7.1
License Number StateMS

VIII. Authorized Official

Name: JON PETERS
Title or Position: PRESIDENT, MANAGING MEMBER AND DIRE
Credential:
Phone: 901-201-5484