MEDICARE: AVELLA OF CHANDLER, 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	Y005093	AZ
2	3336S0011X	Specialty Pharmacy	Y005093	AZ
3	3336C0003X	Community/Retail Pharmacy	Y005093	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	0324157	OTHER		NCPDP

General Provider Information

NPI Number	:	1720083462
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AVELLA OF CHANDLER, 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	:	2155 E CONFERENCE DR
Second Line	:	STE 101
City	:	TEMPE
State	:	AZ
Zip	:	85284-2604
Country	:	US
Telephone Number	:	480-775-4784
Fax Number	:	480-730-9734

Authorized Official
Title or Position	:	CEO
Name	:	JOHN D MUSIL
Credential	:	PHARMD
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 CHANDLER, INC ” Practice Location

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