Healthcare Provider Details

I. General information

NPI: 1124625868
Provider Name (Legal Business Name): AVITA DRUGS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2020
Last Update Date: 10/06/2020
Certification Date: 10/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 RED RIVER ST STE 3A
AUSTIN TX
78705-3214
US

IV. Provider business mailing address

10604 COURSEY BLVD
BATON ROUGE LA
70816-4015
US

V. Phone/Fax

Practice location:
  • Phone: 512-213-4027
  • Fax:
Mailing address:
  • Phone: 225-236-1541
  • 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: ASHLEY ELLIS
Title or Position: CORPORATE COUNSEL
Credential:
Phone: 704-641-7967