Provider Demographics
NPI:1205831955
Name:AVELLA OF GILBERT, INC.
Entity Type:Organization
Organization Name:AVELLA OF GILBERT, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:D
Authorized Official - Last Name:MUSIL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-434-3657
Mailing Address - Street 1:1606 W WHISPERING WIND DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85085-0678
Mailing Address - Country:US
Mailing Address - Phone:623-434-1700
Mailing Address - Fax:623-434-3673
Practice Address - Street 1:2450 E GUADALUPE RD
Practice Address - Street 2:STE 110
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85234-5116
Practice Address - Country:US
Practice Address - Phone:480-633-6934
Practice Address - Fax:480-633-6974
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:APOTHECARY HOLDINGS, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-06-19
Last Update Date:2013-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZY0050833336C0003X
3336C0004X, 3336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ698318Medicaid
0326721OtherNCPDP PROVIDER IDENTIFICATION NUMBER
AZ698318Medicaid