MEDICARE: AVELLA OF GRAYHAWK, 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	3336C0004X	Compounding Pharmacy
2	3336S0011X	Specialty Pharmacy
3	3336C0003X	Community/Retail Pharmacy	Y005092	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0324967	OTHER		NCPDP PROVIDER IDENTIFICATION NUMBER
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1376548016
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AVELLA OF GRAYHAWK, INC.

Provider Business Mailing Address
First Line	:	1606 W WHISPERING WIND DR
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85085-0678
Country	:	US
Telephone Number	:	623-434-1700
Fax Number	:	623-434-3673

Provider Business Practice Location Address
First Line	:	7336 E DEER VALLEY RD
Second Line	:	STE 100
City	:	SCOTTSDALE
State	:	AZ
Zip	:	85255-7455
Country	:	US
Telephone Number	:	480-538-0699
Fax Number	:	480-538-0795

Authorized Official
Title or Position	:	CEO
Name	:	JOHN D MUSIL
Credential	:
Telephone Number	:	623-434-3657

Provider Enumeration Date	:	06/17/2005
Last Update Date	:	04/30/2013

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Directions to “AVELLA OF GRAYHAWK, INC. ” Practice Location

Language	Start Address	Practice Location

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