MEDICARE: AVENUE HEALTHCARE ENTERPRISES 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	3336C0003X	Community/Retail Pharmacy

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	333600000X	OTHER	PA	PHARMACY
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1336467836
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AVENUE HEALTHCARE ENTERPRISES INC

Provider Business Mailing Address
First Line	:	1111 AVENUE OF THE STATES
Second Line	:
City	:	CHESTER
State	:	PA
Zip	:	19013
Country	:	US
Telephone Number	:	484-816-0344
Fax Number	:	484-816-0296

Provider Business Practice Location Address
First Line	:	1111 AVENUE OF THE STATES
Second Line	:	STORE #2
City	:	CHESTER
State	:	PA
Zip	:	19013
Country	:	US
Telephone Number	:	484-816-0344
Fax Number	:	484-816-0296

Authorized Official
Title or Position	:	PRESIDENT/CEO
Name	:	MR. KAYODE EBED-MELECH BALOGUN SR.
Credential	:	R.PH, M.SC
Telephone Number	:	484-816-0344

Provider Enumeration Date	:	05/07/2010
Last Update Date	:	01/28/2022

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