=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063235653
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AVAIL RX LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/04/2024
-----------------------------------------------------
Last Update Date | 11/04/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 116 DEFENSE HWY STE 103
-----------------------------------------------------
City | ANNAPOLIS
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21401-7040
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-292-3633
-----------------------------------------------------
Fax | 443-272-4733
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 116 DEFENSE HWY STE 103
-----------------------------------------------------
City | ANNAPOLIS
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21401-7040
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-292-3633
-----------------------------------------------------
Fax | 443-272-4733
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PIC
-----------------------------------------------------
Name | TIPPAWAN NONTHANAM
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 443-292-3633
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------