MEDICARE: AVG INC

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	3336L0003X	Long Term Care Pharmacy

General Provider Information

NPI Number	:	1326071572
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AVG INC

Provider Business Mailing Address
First Line	:	8700 SANTA MONICA BLVD
Second Line	:
City	:	WEST HOLLYWOOD
State	:	CA
Zip	:	90069-4508
Country	:	US
Telephone Number	:	323-475-1475
Fax Number	:

Provider Business Practice Location Address
First Line	:	8700 SANTA MONICA BLVD
Second Line	:
City	:	WEST HOLLYWOOD
State	:	CA
Zip	:	90069-4508
Country	:	US
Telephone Number	:	323-475-1475
Fax Number	:

Authorized Official
Title or Position	:	CEO/CFO/SEC/DIR
Name	:	TRISTAN DAVID SCHUKRAFT
Credential	:
Telephone Number	:	818-231-0751

Provider Enumeration Date	:	07/09/2006
Last Update Date	:	07/05/2022

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