Provider Demographics
NPI:1326071572
Name:AVG INC
Entity Type:Organization
Organization Name:AVG INC
Other - Org Name:ADVANCECARE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO/CFO/SEC/DIR
Authorized Official - Prefix:
Authorized Official - First Name:TRISTAN
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:SCHUKRAFT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-231-0751
Mailing Address - Street 1:8700 SANTA MONICA BLVD
Mailing Address - Street 2:
Mailing Address - City:WEST HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90069-4508
Mailing Address - Country:US
Mailing Address - Phone:323-475-1475
Mailing Address - Fax:
Practice Address - Street 1:8700 SANTA MONICA BLVD
Practice Address - Street 2:
Practice Address - City:WEST HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:90069-4508
Practice Address - Country:US
Practice Address - Phone:323-475-1475
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-09
Last Update Date:2022-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0589905OtherOTHER ID NUMBER-COMMERCIAL NUMBER
CAPHA471720Medicaid
CABT9420871OtherDEA #
CAPHA471720Medicaid