Healthcare Provider Details

I. General information

NPI: 1417529363
Provider Name (Legal Business Name): AVITA DRUGS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2021
Last Update Date: 07/12/2021
Certification Date: 07/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

426 BUTTERNUT ST STE A
ABILENE TX
79602-1327
US

IV. Provider business mailing address

5700 GRANITE PKWY STE 425
PLANO TX
75024-6648
US

V. Phone/Fax

Practice location:
  • Phone: 325-480-8989
  • Fax: 833-866-0493
Mailing address:
  • Phone: 469-592-2010
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: CHAD BROOKER
Title or Position: REGULATORY COUNSEL
Credential: JD
Phone: 469-592-2010