MEDICARE: AEVA II LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	333600000X	Pharmacy

General Provider Information

NPI Number	:	1164924197
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AEVA II LLC

Provider Business Mailing Address
First Line	:	6280 S VALLEY VIEW BLVD STE 732-736
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89118-3809
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4641 BLUE DIAMOND RD STE 120B
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89139-7610
Country	:	US
Telephone Number	:	702-558-2382
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	BARBARA DEINET
Credential	:
Telephone Number	:	702-219-6173

Provider Enumeration Date	:	03/06/2018
Last Update Date	:	09/18/2018

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